Here's How the New Weight Loss Drugs Could Change Everything

17 Aug 2023 · 55 min

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```markdown Odd Lots Podcast Episode Summary

Episode Title

Here's How the New Weight Loss Drugs Could Change Everything

Episode Overview In this episode, hosts Joe Weisenthal and Tracy Alloway discuss the emergence of GLP-1 medications, such as Ozempic and Wegovy, originally created for diabetes treatment but now recognized for their significant weight loss effects. The episode features insights from James van Geelen of Citrinitas Capital, who evaluates the broader economic impacts of these drugs.

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Key Concepts and Discussions

Introduction to GLP-1 Drugs

  • Definition: GLP-1 (Glucagon-like peptide-1) medications help regulate insulin and suppress appetite.
  • Examples: Ozempic, Wegovy, and Mounjaro.
  • Original Purpose: Designed to treat diabetes but showed significant weight loss as a side effect.

Economic Impact of GLP-1 Drugs

  • Stock Market Reaction: Companies like Novo Nordisk and Eli Lilly have seen their stock prices soar due to the rising popularity and efficacy of these drugs.
  • Broader Economic Implications:
  • Obesity has been a major burden on healthcare systems and the economy, with significant costs associated with treating obesity-related diseases.
  • The possibility of reducing obesity rates could lead to lower healthcare costs and improved productivity.

Guest Insight

James van Geelen

  • Background: James has experience in the medical field and now focuses on thematic investing in biotech and medical technology.
  • Investment Approach:
  • Evaluates drugs based on their potential clinical benefits and societal impacts.
  • Uses a network of medical professionals for insights on drug efficacy and market trends.

Weight Loss Drug Mechanisms

  • How They Work: Mimic natural hormones to enhance insulin secretion and reduce appetite.
  • Side Effects: Some gastrointestinal side effects, but generally considered safer compared to past weight loss drugs that had severe repercussions.

Healthcare Dynamics

  • Insurance Considerations: Insurers are beginning to account for the cost of these drugs in their models due to the potential reduction in obesity-related complications.
  • Potential for Government Involvement: Discussion on whether these drugs should be covered as a public health intervention similar to COVID vaccines.

Market Predictions and Company Impacts

  • Consumer Goods and Fast Food: Companies may face reduced demand as consumers take these drugs and experience reduced appetites.
  • Potential Winners and Losers:
  • Winners: Companies in the healthcare sector that provide treatments for obesity-related conditions may benefit.
  • Losers: Fast food chains and companies that offer weight loss products may struggle as effective drug options become available.

Societal Changes

  • Behavioral Shifts: The episode discusses how a healthier population could impact various sectors, such as dating services (e.g., Match Group, Bumble) and overall societal attitudes towards fitness and health.

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Conclusion The conversation reflects on the transformative potential of GLP-1 drugs not only in terms of individual health outcomes but also their broader economic and societal implications. As these medications become more widespread and affordable, they could significantly alter healthcare costs, consumer behavior, and even societal norms surrounding health and body image.

Key Takeaway The rise of effective weight loss drugs signifies a potential paradigm shift in public health and economics, warranting attentive observation from both investors and policymakers.

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Listen to the Episode For more detailed insights, you can listen to the full episode on [Bloomberg](https://omnystudio.com/listener). ```

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Transcript

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1:01Acrobat Studio. Learn more at adobe.com slash do that with Acrobat.

1:16Hello and welcome to another episode of the Odd Lots podcast. I'm Tracy Alloway. And I'm Joe Weisenthal. Joe, would you ever go on Ozempic? Yeah, definitely. I can't wait. Really? Well, yeah, why not? It seems fun. It reduces your appetite, probably lose weight. It seems like it also has a bunch of other, I keep seeing these other things, like it's good for like, you know, impulse control and all kinds of positive things. Yeah, why not? Yeah, it's supposed to be good for impulses and addiction. And also I think there's some new stat out saying that it reduces the risk of heart attack and stroke by 20%.

1:52Well, anyway. Would you? I think, yes. However, I would definitely wait for the price to come down a little bit and maybe for more of the side effects to become apparent. But I'm very cautious with these sorts of medical breakthroughs. Yeah, I am too. I feel like my like I don't know that much about all these drugs like Ozempic and Wegovy and the other GLP ones, but they seem pretty great. And I'm just like, yeah, upward and onward. The march of progress. Science. I love it. No, but I actually do think like it is something I've been thinking about is like people are so skeptical of even the possibility of the existence of a wonder drug that people are like, oh, it's going to do this.

2:36It's going to do this. It's going to be bad. It's going to reverse. It's going to. And maybe that's possible. But what if it really is a wonder drug? Well, exactly. And I think it opens up a ton of interesting questions specifically about what it means for wider society and the wider economy when we know that obesity and diseases like diabetes have been this huge weight on both the socioeconomy and the health care industry. Obesity itself is like just this gigantic economic force. It's a business force. There are businesses that thrive on how much people like to eat unhealthy food. There are huge costs to insurers.

3:16There are other second order effects related to injuries and heart complications and so forth. It's such a modern, important phenomenon that were there to be, and maybe it kind of looks like there is, but were there to be this sort of like straightforward way to reduce obesity, it seems like the implications would be huge. Right. And I keep getting visions of like Star Trek in my head where everyone is kind of slim and dressed in tracksuits and very athletically capable. And we all just wander around spaceships. So that sounds great. Well, anyway, on a serious note, I think we need to dive into these new sets of drugs.

3:53What exactly are they? How do they work? And more importantly, more interestingly, what do they actually mean for the wider economy and the business environment? So many. I'm so glad we're doing this because it does feel like beyond just the companies selling these drugs, which we know have been taken off. We're recording this on August 9th. Just yesterday, Nova Nordisk, the Danish company, soared because they had another test showing that one of these drugs was very good for fighting heart disease. So we know that there's like the interest in the vendors, the sellers of the drugs. But again, what does it mean all these second and third order effects if they really become extremely widespread?

4:32And it kind of looks like they're on that trajectory. It feels very unexplored. Yep. So let's dive into the second order effects of miracle weight loss drugs. A fun episode ahead. We have really the perfect guest. We are going to be speaking with James Van Galen of Citrinitis Capital, also known as Citrini on Twitter. So, James, thank you so much for coming on All Thoughts. Hi, Tracy. Hi, Joe. Thanks for having me. So, James, from what I remember, you actually have something of a medical background. Is that right? Yeah, I worked my way through undergrad as a paramedic for a while in Bridgeport, Connecticut.

5:06And then when I transferred to UCLA, I worked as a paramedic in Compton, California. So I'm not a stranger to the medical field. Then for about four years, I started, co-founded one of Connecticut's first medical marijuana dispensaries. So I definitely am not a stranger to the medical field. Now I do the hedge fund thing and it comes in handy once in a while. Investing in medical technology or biotech often, it seems like this sort of like roulette wheel. And I'm always skeptical that anyone who is like not a scientist can actually have informed insights on new medicines and how big they could get, et cetera.

5:46Can you just sort of like give your overview of like, how do you even like think about these things? Like if you're not like a scientist, how do you even begin to like wrap your head around like, how do these drugs work and how big they could be and which ones have more potential than others? Like what's your like framework for like sort of just like evaluating some breakthrough in the first place? I mean, I don't do a ton of like biopharma investing. I'm not a scientist, but I do have a robust network of channel checks. and I'm a big proponent of basically, if you don't know something, ask, you know?

6:17We are too. So I am, you know, I'm always bothering them and, you know, all it costs me is a couple of dinners or something and, but, you know, I don't do much, if any, investing in companies that are still clinical stage, right? And, you know, a lot of my investing is kind of thematic investing. It's focused on these kind of paradigm shifts, these megatrends essentially. And when you see something like this, right, All the feedback from Challenge X is good. And it's something that we've kind of needed in developed markets, at least for decades. And you just see the kind of behavioral incentives that exist surrounding it.

6:57And I always come back to basically, you look at like Viagra in the 90s. And you did not have to be a doctor to kind of see Pfizer just killing it, just doing amazingly with this drug that solved the problem that people had that, you know, needed to be fixed and it worked. And, you know, honestly, that might be the reason that most of us know who Pfizer is, right? So, you know, whether it's buying Moderna when they're developing a COVID vaccine or buying Eli Lilly when they're developing, you know, a fat vaccine or Pfizer with Viagra in the 90s, it all falls under the megatrend looking for kind of these paradigm dramatic shifts.

7:35I think people forget nowadays that Viagra was initially developed for something totally different to what it's used now. And that happened to be a sort of happy side effect of the medication, I guess. And then it became known for that. But just on this note, let me ask the basic question. So how did these drugs, GLP-1, I'm not even sure what that stands for, but how did these come into being? And how are they starting to spread through the market such that I meet VCs who will openly say that they're on Ozempic, and I'm pretty sure they don't actually have diabetes. Yeah, so GLP-1 stands for glucagon-like peptide.

8:15I don't want to get too scientific, but basically the peptide helps kind of prime insulin release, right? It allows the body to absorb glucose after a meal, and you have specific cells in your pancreas that can recognize GLP-1 through molecules called receptors, right? So essentially, we've been looking into these drugs called peptides. The medical field has been looking into them since the 70s. And GLP-1's primary benefit was the fact that it was able to reduce blood glucose levels via insulin release, which is very desirable in a patient with diabetes. And the thing was, when it comes to peptides, normally you're trying to mimic the peptide that your own body produces.

8:54So the actual molecule, glucagon-like peptide 1, is only able to create these effects for a very short time span. And so what these genius engineers discovered was that they can essentially mimic these hormones and have these molecules that bind to the receptors. They're called agonists, right? And that can create an effect that lasts, you know, four hours or even weeks. And that was basically the basis of the initial development. And the impetus for it was essentially to go after diabetes, right? If you have something that can regulate glucose that is possibly dysregulated in a patient with diabetes, that's kind of something that seems desirable, right?

9:39So they were kind of predicted to also prolong this feeling of, you know, fullness and slow gastric emptying. And they also provide a variety of effects in the brain. And these drugs do cross the blood-brain barrier. And the first GLP-1 drug that was approved by the FDA was exenatide. It was marketed under the name Bayetta. So Bayetta was approved in 2005, right? And primarily to be used in type 2 diabetes. And while you have something like semaglutide right now, which is ozampic, it's a generic name for ozampic. And then Munjaro, which is Lily's drug, terzapatide, is the generic name. And the thing is, once you have a class of drugs, you can kind of anticipate what the side effect profile will be.

10:28It's not necessarily that you can anticipate every single side effect, but you get an idea of the structure activity relationship. You get an idea of this dose dependent curve and where side effects start becoming apparent. And so with GLP-1s, they have side effects, right? They have some GI side effects and these GLP-1 receptor agonists like semaglutide, they can be pretty bad. But what Lilly saw was essentially, it was decided that they would try to go after different receptors in the same system, right? So they kind of get this, it's like terzapatide, Mujaro, is basically a dual GLP-1 receptor and then GIP receptor agonist.

11:12So the way that that works is the GIP activity allows you to take a higher dose before experiencing the side effects, the GI side effects. And we also kind of know, you know, since these drugs, you know, Trulicity was a big one that was approved in, I think, 2014 for type 2 diabetes. It saw very wide use. So when you encounter someone and they're like, oh, you know, no, for sure, these drugs are going to melt your insides. You know, like, I don't blame them for that. Because if you look at the history of weight loss medication, you think fen-fen, right, which like basically melted your heart. Then, you know, Ramona Band, which was like this genius invention where the scientists were like, well, you know, the cannabinoid receptors, basically the receptors that THC act on, those make you hungry.

11:57So if we block those receptors, then it should make you not hungry. And it did. But you know what else that cannabinoid receptors make you is happy. So I don't know how they didn't see this coming, but it made people very sad and increased the likelihood that they would commit suicide. And so that drug was pulled very quickly. And, you know, you kind of look at the past of the weight loss industry, people taking, you know, tapeworm pills and just doing absolutely insane things. And it's kind of like, OK, now you have this drug. And the absolute worst concern, you know, that there's a warning on the FDA label is that it may, you know, it may result in thyroid cancer.

12:35But the thing is, the only time that that's ever been observed with these GLP-1 drugs is in mice. And the thing about mice is when you're doing a trial with a mouse, the mouse is not going to tell you, I can't handle these side effects anymore. I'm going to stop taking the injection. Right. No mice drop out of trial studies. So what happens is, you know, like the if you were to take the equivalent dose that caused, you know, these endocrine cancers in mice, before you reach that point, you would be so sick to the level of not being able to function. And so the dose was much, much higher. And that, you know, it has not been observed in humans.

13:14And the other thing is, this is probably a little controversial, but the fact is, like, obesity is devastating, right? It is absolutely terrible. The way that increases mortality, I mean, And I'm going to drop some statistics that Lily dropped on the earnings call, which is that, you know, there are 236 obesity related health conditions. Type two diabetes risk is increased by 243 percent in people with obesity, heart disease by 69 percent, high blood pressure by 113 percent, high cholesterol by 74 percent. and the contribution to all cause mortality is so significant that essentially if I had a drug that would, again, this has never been observed in humans.

13:57It's probably not going to be because of the relationship that I described with the dose. But let's say I had a drug that 100%, no matter what, in 40 years, you're going to develop thyroid cancer from it. even if that was the case, if it also 100 % of the time made you not obese anymore, the net effect on your life expectancy would still be positive.

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15:42step of the supplier life cycle, helping you deepen merchant relationships. Start fast, grow strategically, and scale at your pace with a modular toolkit you can flexibly deploy. Discover how at MasterCard.com slash commercial acceptance. You know, so you mentioned in the beginning that you as an investor, you like to think about people called paradigm shifts or megatrends and so forth. And one of the things that thinking about it in this context. And I think there is a very good argument. I'm basically sold that the rise of these drugs will constitute a paradigm shift or a megatrend or something like that.

16:21And I feel like many people buy that. But the other thing is that like betting on megatrend often is not trivial in terms of even if you can predict the trend, you might not know what to invest in. And so, you know, a good example might be, say, like the rise of Chinese industry or something like that over in the, you know, in the 21st century since its entry into the WTO. And it's not like I don't think like buying like Chinese stocks have like been like some like extraordinary winner, certainly like long stretches of time where that doesn't work. So like what's the next step from identifying megatrend to then thinking about, OK, these will be actual winners as public market investments?

17:01Well, let me talk a little bit about hype, right you just had dan loeb and talking about how it's more important to monitor you know reddit boards than it is to monitor fundamentals before pros baby tracy's uh tracy's message on her bloomberg tracy's ready to ready to spin up a fund that takes advantage of that i think she's very pro the reddit investors what was that the guy in the basement has the edge if that's the case yeah well it's all about the story all about the narrative right and the guy reading reddit might have a better handle on that. But go ahead. Right. This kind of, you know, memetic investing.

17:37So, you know, you guys ever heard of the Gartner hype cycle? Yeah. For those who haven't, the way that it looks is you have this kind of parabolic rise between the technology trigger and then the peak of inflated expectations and kind of the axiomatic way to give an example of this would be the dotcom bubble. Right. You have the technology trigger, which is the Internet, And then it kind of goes parabolic all the way up to the peak of inflated expectations, which would probably be, you know, in 1999, pets.com type stuff where the things that are happening are absolutely ridiculous. Right. The forecasts are insane.

18:12And the thing about a megatrend or, you know, a theme that is persistent is it doesn't go unnoticed for very long. It can be a significant amount of time. But, you know, you speak about like Chinese industry in the 21st century, you know, like there was a period of time where you could have been early on that and you could have invested and made excellent returns that, you know, the peak of inflated expectations and then kind of exited before. Or I guess I think maybe there was kind of a biphasic. So maybe it would have been the Asian currency crisis. But then what happens is you get this trough of disillusionment, right, where it's like this technology isn't real.

18:49Everything is kind of hyped up. It was all BS, whatever. It was a bubble. And then exactly. It was a bubble. And then you get this. Well, you know, the funny thing is people say it's a bubble while it's going up, which is kind of like when people say, you know, like, OK. This is the difference between a journalist and investor, which is like blah, blah, blah, blah, blah, blah. And then other people are out making a fortune. And it's like, this is why no reporter should ever get into trading. I mean, you know, like how long was, you know, Bitcoin had an awful year last year. But like how long was it going up for before, you know, like obviously it was a bubble.

19:28But like, you know, that doesn't mean that you have to like be like a monk about it. You don't have to have this monastic view where God forbid I benefit from a bubble. You know, those people are wrong. Who cares? So anyway, you get to kind of this trough of disillusionment. And then the next phase is kind of the slope of enlightenment where, you know, to borrow a phrase from the VCs, it gets democratized. You know, you can go out in the street right now. If I go out on the street and I ask someone what the Internet is, they're going to look at me like I have five heads. They don't necessarily have to know how it works, but they know what it is.

19:58And then you get the plateau of productivity. In the prototypical Gardner hype cycle, the plateau of productivity is actually below the peak of inflated expectations. But I think most of the time in markets, it's actually higher. Obviously, there's a bit of survivorship bias on this. You know, nobody that owned Pets.com benefited from the plateau of productivity. But if you think about, you know, Facebook, Amazon, Apple, you know, these, you know, they or even, you know, you look at like the nifty 50 in the 70s, right? Right. Like some of them have had very bad returns like IBM. But then, you know, Honeywell or Carrier Global, you know, you get the uptake on the GDP effect.

20:39And essentially, this is kind of the enemy of the megatrend. Right. Because it's very easy to recognize it in the beginning. And then if you're too late with it, you're going to think that the peak of inflated expectations is just a pullback. Right. When it's not, you know. So this is kind of something where it's good to continuously monitor whether your thesis is playing out, whether it is actually, you know, whether it's artificial intelligence or, you know, like you said, the rise of Chinese industry or the Inflation Reduction Act and the impact and impetus of fiscal spending or, you know, GLP-1 drugs.

21:15So as long as you are on top of it and you can see, you know, what are the earnings expectations like and what are the actual, you know, like like NVIDIA is probably going to, you know, beat and raise for the next couple of years. But then, you know, where is going to be the point where the expectations aren't sustainable? And when it comes to, you know, you said you wanted to talk about the knock on effects, which kind of I mean, that's my favorite part of these things. Right. Like like when you actually capture a theme and, you know, let me ask you a question. Like, do you think the knock-on effects are happening yet?

21:47I don't know what the take-up is. So my impression is that, actually, we should ask, how much do these drugs actually cost? Because my impression is that they're pretty expensive, and so they're not making huge inroads into the general population just yet, but that could easily change. Well, you know, right now, as far as weight loss is concerned, as an FDA on-label indication, Novo has Monopoly, right? Novo has Wagovi, which is the drug that just had the big headline about 20 % reduction in heart attack risk. And essentially, they can charge what they want, right? And the way that it's going to develop is Lilly's drug, Munjara, which is much more effective, and their other drug, Redistrutide, which is still in clinical trials.

22:35But Munjara will be approved for weight loss at the end of this year. that was reaffirmed within the next six months, right? That was reaffirmed by Lilly on their earnings call. And let me get the answer to the question first because I want to go into something that's going to answer your question, but I do want to assess, right? Do you think that the knock-on effects are happening yet? No, so actually, I've been wondering about this because I actually was kind of under the impression, like, when are we going to see a company crash on earnings because they say, you know what? We're seeing our sales collapse.

23:08No one's eating our cheeseburgers. Has it come up on any like fast food calls yet? Has it come up on any like CPG company earnings calls yet? Like I remember like last quarter, like Chegg, the textbook company said like, we're running into trouble because AI is like affecting our ability to sell this product that helps people with their homework. So have we seen that? No one will ever say that again. You know that, right, Joe? Yeah. Even if it's happening, no one will ever blame AI again. They know what happened to Chegg. So is there other companies yet that are saying, you know what, in our customer base, we're seeing a change in consumption patterns of something because of these drugs?

23:45A ton. Really? A ton. Yeah. So just to go through a couple. Right. And this will answer your question, Tracy. Right. Where first off, yes, the drugs are expensive. These drugs cost about$800 to$1 ,200 a month, you know, which is a lot. And that is for Ozempic and Mugobi. And like I said, you know, you don't have anything that makes this much money that doesn't have competition. Right. So, yes, Lilly will get approved for Munjaro on weight loss and then there will be a duopoly. And that'll probably last, I don't know, you know, anywhere from a year to three years or something like that. But to come back to Viagra, right, if you think about it, Viagra in 1998 cost$88 a pill.

24:28OK, now it costs two. There is, whether it's through generics, whether it's through competition, you know, the Cialis, the way that it works is, you know, you have competition, you have economies of scale, you have insurance coverage, you have, you know, the generic drugs eventually. GLP-1s, in fact, in 2031 will face mandatory discounting under the Inflation Reduction Act. So are they expensive right now? Yeah. But, and to come back to what we were saying before, that still did not, you know, GLP-1s were mentioned a thousand times in the Q2, Q3 earnings. Wow. That's interesting. And only half of that was by pharmaceutical companies.

25:09Okay. I just did a transcript search and there's a Herbalife earnings transcript where they talk about GLP-1 drugs possibly impacting the business. I will never short Herbalife just because... We all saw what happened with that. I am always willing to learn from another person's mistake. But best of luck to Ackman if he wants to go after it again. But if you have document search up, Tracy, you can look at Metafast. Yeah. and Metafast. Yeah, Metafast. Herbalife didn't get hit as bad. I don't know what that was a function of. I think they tried to explain it. I didn't really vibe with the explanation.

25:49But Metafast basically said that, we sell things that people use to lose weight and we cannot handle the competition from a drug that actually works. I think the direct quote was that you know, customer acquisition is being pressured by GLP ones. But you know what they're doing now? Their strategy is essentially, okay, let's do it too. You know? Yeah. Everyone else is making, right? Didn't Weight Watchers do something similar? Yeah, exactly. And that, you know, I love a company that is like twerked up, levered, melting ice, priced like a melting ice cube, and then positioned right in the center of like a, you know, like a burgeoning, you know, huge trend, right?

Read the full transcript

26:35Because, you know, like a good example from another trend, artificial intelligence would be like applied opto-electronics, right? Which is like, like it was destroyed. And then, you know, with 800G and the data center demand for optical, you know, it's a, we're so back, right? Weight Watchers. It's so over. It wears so back. It was so over. I hadn't heard of Metafest, but I'm reading their descriptions. Yeah, they talk about competition. And among the things that they make are pretzels, puffs, cereal crunch, drinks, hearty choices, oatmeal, pancakes, pudding. So I'm basically, I don't know, maybe the products are delicious.

27:12But I'm imagining the type of things that people who are sort of like really trying to lose weight are like, oh i'm gonna eat these puffs and shakes because they're a little bit healthier than the alternative i mean you don't need to that's the thing you don't need to work like like you know i was talking about my channel checks earlier and i have an endocrinologist you know like um eli lily was one of my biggest positions from you know 2022 2021 even and it kind of got surpassed during the ai stuff but i built up uh basically you know like i would go to like an end of whenever you have a position that's super big you know you're on top of it right you and you can expense a trip to an endocrinologist conference.

27:48And you go there and like, I'm speaking to these people and they're like, I have a patient who was eating 5 ,000 calories a day, which is like a full-time job, right? Like, like 5 ,000, once you get to like 5 ,000, 6 ,000 calories, that's like, I mean, that, that is like eight full meals a day. Right. And he's like, I am, he's having issues because I have to recommend protein supplementation because he can't get above 500 calories a day. So if you look at a company like Metafest, that's basically, you know, selling this food that's a little bit healthier for you and, you know, maybe taste the same so that, you know, you don't have to, you're kind of getting better macronutrients or something.

28:25I mean, there might be an opportunity there for the protein shakes. But overall, like you don't really need to worry about if you're taking this drug, you don't really need to worry about, oh, you know, let me buy food that's like more that's less calorically dense because like it doesn't matter. You're not going to eat it anyway. and this is kind of interesting because when you're looking at when you're like monitoring social media you know like uh always monitoring like you know google trends wikipedia trends and for a little bit i think this was like the middle of last year you know monitoring google trends and this google trend comes up called ozempic face oh yeah this is when people get really gaunt from weight loss literally like i had and i'm like my fingers on the cell button i'm like if it affects your face, like I'm out, you know, and it turns out like people were like, oh, God, like Ozempic causes you to have like, you know, like a gaunt face or something.

29:14And it's like, not really what's causing you to look gone is the fact that you're losing a ton of weight very quickly. Right. And you have another one where like people are like worried about hair loss. And, you know, that is it's a condition called collagen effluvium, right, which is basically the same thing. When you lose too much weight, you know, your body is kind of like burning nutrients for energy, you're at a caloric deficit and you lose care. It's totally reversible. And with like Ozempic face, it's like you can't see wrinkles on like an inflated balloon, right? Like that's just how it works.

29:45And it's kind of amazing to me because you have this kind of impetus where people are like, oh, like this is that this is the like we gotcha. You know, I knew there was going to be a catch. And it's like people are so unaccustomed to the idea of there being a weight loss drug that works, that they are confusing the side effects of the drug with the side effects of the effects of the drug, which is, you know, success being successful weight loss. Just for what it's worth. I'm sorry. I keep going back to this. I'm reading the Metafest transcript from earlier in the week. And one of the one of the questions is Herbalife doesn't say anything.

30:19I'm paraphrasing. One of the questions from the analysts is Herbalife didn't say anything about GLP one drugs affecting their business. What about you? And they're like, well, we're not going to comment on Herbalife, but yes, we're feeling it. So yeah, it actually, it came up. They also cited higher customer acquisition costs. Again, they say pressured by less prospects being identified by coaches impacted by competition from GLP-1 drugs, inflationary pressure. So it's coming up. Wait, so can I ask a basic question here? Wait, wait, just before we go further, can I ask a basic question, which is like, how many people are on these drugs right now?

30:53I mean, so I would rather not comment right. I think that i would never be talking about something like this if i didn't think that it was early right and the so like you can look at penetration like type 2 diabetes right you know talking about like penetration of a drug that's been approved for an indication for a year you know it's like like you're not really going to get an accurate picture you know and manjaro and also a drug where like there's only been one approved for you know and then you get also the fact that like there are talking about, you know, mentions on earnings, there are significant supply chain issues with these drugs, you know, like like Novo is having trouble sourcing the drugs coming in auto injector, right, which is basically if you think of an EpiPen, you know, you take it once a week and, you know, it's like a button that you push.

31:38But you look at like like talking still about like the earnings mentions. If you look at Stevanotto or Gerashimer or even Becton Dickinson, the problem is that they can't produce enough of it, which should tell you something about demand, right? Like, like, even I knew this would turn into a supply chain episode eventually. Please don't try to get me to talk about the slide. I will seem very silly. But the thing is just even Lily, right? Obviously, they have to temper their optimism, but they're having to ramp up production at all, you know, five global facilities just because of the fact that like They're like overwhelmed.

32:17They could not even have anticipated this level of demand. Right. During Lilly's earnings call, Chris Chibitani, an analyst, was asking a question that was basically like, Novo and Lilly, you've been confronted by this demand that was like beyond what you could have possibly planned for. And with Lilly, you know, Manjaro isn't even approved for weight loss yet. And so essentially, it would be kind of premature to say, you know, what the penetration of these drugs is right now. But what I will say is that, and I have a chart that I can send you, maybe you can put it up on the site, that essentially the obesity rate in the U.S.

32:58in 1974 was 12%, right? And now it's 42%. And for the past five decades, there have not been two sequential years in which the obesity rate has ticked down. It hasn't happened for 50 years. So, you know, when you look at that, first off, I think it's not just reasonable, but rational to think that you can't have a society that has both advanced medication and then half of its populace affected by a disease and not think that eventually those two things resolve each other. Right. And if you look at the 68-week trial data on Manjaro and you adjust for the average compliance and which patients dropped out prematurely, and then you adjust for the fact that after you drop out of the trial about half of the weight loss, you still maintain about half of the weight that you lost, but about half of it goes away.

33:52and you so you adjust for all those things if munjaro a 68 week trial data has a 30 penetration rate in the obese population right the obesity rate in the united states would be lower than it was in 1997 and you know like that could happen over the course of two or three years and so for a line that has gone up into the right to go down you know that significantly

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36:01Brokered services for U.S.-listed registered securities, options, and bonds and a self-directed account are offered by Public Investing, Inc., Member FINRA and SIPC. Crypto trading provided by XeroHash. Complete disclosures available at public.com slash disclosures. So I'm not surprised that, you know, mentions of GLP-1s are popping up on various conference calls. You know, some in obvious ways, like the company that maybe makes the devices for its use, or the companies that have some other weight loss solution that may be feeling pressure. But like, for example, today, again, August 9th, we got earnings from Wendy's.

36:38No mention of GLP-1 there yet. I looked last month, we got earnings from Pepsi. And, you know, if I were to think about like, OK, in theory, in some future world where these drugs are very cheap and widespread and who would theoretically be losers from from drugs that reduce one's appetite for fast food, for salty foods, for high carb foods. whatever it is, in your mind, is it obvious that A, some of these big consumer oriented companies are going to be losers? And B, if it is, when would you expect to see what pick out, predict a quarter when maybe this would come up on a Wendy's earnings call?

37:18Well, so let's, you know, first off. Or if the premise of the question is totally off the mark, that's fine, too. No, no, no. I mean, it's a I don't know. We're talking about second order effects. This seems a little first order, Joe. OK, you're right. You're right. No, but no, no. I mean, it's a great point. Right. And I think that, I mean, you know, Wendy's sells so much food. Like it's it's it's me too. I don't want to malign Wendy's. But the thing is, I think that if you wanted to be able to predict this, what you would have to do is you probably have to use all data or, you know, credit card data.

37:55and you would have to look at the company and maybe eat a lot of fast food for a month to figure out. But like which of these companies are making, you're going to be my new analyst. No, which of these companies are willing to or are basically making up for low margins with high volumes, right? Because the because it's not like these drugs are going to automatically make you, you know, the Jack LaLanne, right? Like you're not going to you're not just going to be like the health, all your habits are healthy now. Like if you're eating fast food every day, you will probably continue to eat fast food every day.

38:28You will just eat a lot less of it, like a lot less of it. And let's say Chipotle, for example, probably not going to be that negatively affected, you know, like like people, you know, they'll probably have the same order and they'll just finish, you know, a couple of bites of it or something. I don't necessarily want to speak to this, but just thinking of like Arby's, for example, I think is owned by a private companies so i can you know talk about without issue but like the prototypical let's just speak theoretically there's you know all you can eat buffet or something they might do really well because people eat less but at the same time they might be patronized less because you know nobody wants all you can eat you're not getting a good deal anymore so if you have a company and you look at the data and basically the way that they make money is by selling a ton of food that they get very cheaply and make up for, you know, kind of lower margins by selling a ton of it, that company probably isn't going to do too great.

39:21But, you know, it wasn't just Metafest, for example, you know, going beyond the idea of like food being impacted. Like right now, Lilly has a trial for Munjaro. Basically, what these companies are doing is they are on this kind of blitz scale for like the data, right? Because like most of these things you can kind of rationally expect, like, for example, with the WGOVI headline, WGOVI reduces heart attack risk by 20%. I mean, kind of like, duh, you know, like, oh, like, you know, if you go from being obese to not obese, you're going to have a lower chance of heart attack, right? But what they have to do is, you know, have these, you know, rigorous trials that actually prove it.

39:59Like, so for example, Lily is going right now for obesity-induced sleep apnea or knee osteoarthritis. And so like a company like ResMed, Right. ResMed was talking about it for, you know, like a while on the earnings call. And the response was essentially, you know, I'm trying to remember exactly what they said. Oh, right. CPAP machine. The costs over a lifetime for a CPAP machine are like about$15 ,000. And then they did their own math, which was like, well, these GLP-1 drugs cost$1 ,000 a month. And if you multiply, if you have a 40 year old patient and you multiply that by 40 years, well, really a GOP one drugs, you know, it's going to cost you$480 ,000.

40:41So obviously, you know, we're coming in at 14, 15 ,000. We're obviously the option. We're not going to be really affected by this. And, you know, to take that into consideration, you say, why would people be taking this for 40 years? Right. Why would if someone, you know, 70 percent of sleep apnea is caused by obesity. if you have someone that's taking it and they take it for, let's say, 16 months and they go from being obese to having a normal body weight. And then in all likelihood, at least for like 70 % of them, the obstructive sleep apnea goes away. I mean, you have to adjust kind of the total addressable market for a company like ResMed or for the CPAP industry in general.

41:22It is going to shrink, right? It's kind of, and even, you know, and then when people say that, you know, this is a fad or, you know, this won't work again. You look at like, like, when was the last fad weight loss drug that had intuitive surgical talking about on the earnings call, right? Like intuitive surgical, they're not ready to speak to it, but they mentioned it on the earnings call. And then you have another company that I think this was my favorite one, right? And it wasn't even because of anything the company did or said, it was just because I'm reading the prepared remarks. And And the exact text was basically, you know, so the company is called Teleflex.

41:58And essentially, it's a company that makes devices for sleeve gastrectomy, like the bariatric surgery, weight loss surgery. You get the sleeve. And the thing is, you know, a sleeve gastrectomy, I think the average weight loss over 72 weeks is like 26 or 27 percent. And with Munjaro, it's a little bit closer to, depending on the dose, between like 17 and 19%. But Lilly's new drug, the triple agonist, retitrutide, is showing like 24, 25%, right? So in the prepared remarks, they're basically saying, we did see an effect from GLP-1s on the demand for bariatric surgery, which affected the demand for our device, the Titan stapler.

42:46so if i ask you tracy if you want to lose weight would you rather take a stomach or get or get titan stapled yeah like who like like you you want to go with the titan stapler i don't think so why didn't they call it like soft staple or gentle staple titan is just a terrible name for any surgical procedure okay wait so one of the reasons talking about this is fun is because it is kind of a giant thought experiment of what a world of fewer obese people would actually mean. How far can you take it, James? Like, what's your most interesting sort of second order trade idea based on a widely available weight loss drug?

43:31Well, I think that, you know, if I'm going to stretch this as, you know, as far as it can go, the first thing is stretching it as far as it can go gets pretty stretched because Because, I mean, the direct medical costs this year from obesity are going to be$370 billion. The indirect costs are going to be over a trillion. McKinsey, in 2012, when the obesity rate was like, I want to say 7 % or 8 % lower, they estimated that obesity results in an annual global economic impact that is equivalent to 2.8 % of the global GDP. So you think about productivity, sick days, workers' comp, injuries. I mean, life insurance, health insurance, workers' comp insurance, something like that.

44:13When you have a literal disease state that is affecting 42 percent of your population, it's kind of hard not to stretch this far, you know, like if that gets fixed. But in terms of the one that I would share on a podcast to be entertaining, I would say like Match Group or Bumble as a long. If you look into like just general sociological. Everyone feels better about themselves. And so they go out in a product in the dating marketplace. And, you know, what's interesting about this, you know, match group, I already think that the fundamentals look good here. But, you know, if we're going to like stretch it super far, you look at like match groups last earnings and like payers were flat or decreased a little bit for Tinder, but they increased significantly for hinge.

44:57And if you look at like there are like, you know, social sciences studies about like the effects of obesity on like your how happy you are and how satisfied you are with your dating life and stuff. And I think I don't want to butcher the results or something, but it was basically across genders, right? Like if you are a female or male, the effect of losing 10 or 20 pounds on your average, you know, satisfaction with your dating life and with just generally how happy you are, it's a lot more significant in females. So, you know, maybe if you want to like be super early and stretch it super far, maybe the reason that like hinge is getting more popular than tinder maybe it's because it's easier to lose weight i don't i would not say that in like an authoritative way but you know you'll just say it on the bloomberg yeah no yeah that's the only thing i'm gonna get quoted on right like like all the quotes are gonna be like no this is this is a crazy guy thinks that like match group is gonna moon because of but you know no i guess i just say i get i get how the internet works though i know you do i know you do uh it's funny i keep reading through conference calls after you mentioned them.

46:04I'm looking at the ResMed one. Did you look at the Titan stapler? No, but they're talking about, they're like, well, they're like, because clearly this is a source of anxiety for them. So they're like, oh, well, like uptake and like endurance is not really that good. And then a very funny thing they say, because Biden had that mark on his face, is our biggest side effect is President Biden had a little mark on his face and he was asked about it. And it was from his CPAP. Look, I think it's a good long road to play out here. I think it's frankly, good marketing. So President Biden, because he had to put a device on his face for his sleep problems, the company is setting.

46:36I mean, I saw I saw a photo of Justin Trudeau at IMAX. Yeah. So maybe I should get long IMAX. You know, it seems like a big deal. Like just zooming out. It seems like a big deal, even if we like set aside what it's going to do to Pepsi or what it's going to do to like Frito-Lay or that's the same company, you know what it's going to do to all these consumer companies. You know, health insurance, you mentioned that like obesity plus obesity related diseases are huge. And so if they were to go down and you see, maybe you see some of that in a sort of weak stock price of ResMed anxiety about this, what does it mean just like for like health insurers and also just like healthcare utilization in general?

47:17Like, you know, generally we think of like healthcare as like a line that only goes up that if you're a healthcare professional, you're like going to do probably likely very well, guaranteed demand. What is the effect on just sort of like the broader healthcare, institutional healthcare industry? Since you already got document search loaded up, why don't you check out Insperity? The ticker is NSP. This is a fun game. I like just hearing different names and then I look them up during the answer. Yeah, keep going. Welcome to my life during earnings season. Document search is my favorite feature.

47:51But You know, if you look at Insperity, you can kind of see, I don't want to misquote anyone, so I'll just pull it up very quickly. Oh, look at the share price. Wait, this is, the company offers recruiting, employment screening, retirement, business insurance. Yeah, what is this company? It's down about 16 % year to date. That's what matters. I can't figure out what they do and what their connection is here, so we're going to find out. Provides human resources and business optimization services. No, no, no. Yeah, but I don't, okay, so what's the deal? So here's the deal. Right. They also offer, you know, employee benefit administration.

48:24Yes. Which, you know, like health. And so if you want to boil it down to two things, like insperity got hit on the fact that like people want these drugs because they don't want to be fat and the drugs make them not fat. And insperity apparently thinks that, you know, that is a fad. They were saying something that was like, oh, you know, the effects are going to wane because of the side effects. And when you think about it, like these drugs were originally developed for type two diabetes. And it's like, oh, you know, there's never been a drug before that was developed for one thing and then ended up being really good for the other, you know, just like Tracy said with Viagra.

48:55And basically, they said, you know, large claim activity accounted for approximately 75 percent of the higher costs with claims over seven hundred fifty thousand dollars. And the remaining 25 percent is related to higher than expected pharmacy costs. As for higher pharmacy costs, we experienced an increase in utilization of the specialty drugs, including a significant step up in the use of diabetes and weight loss drugs. And then they talk about behavioral health drugs, behavioral health drugs, too, which is probably, you know, I mean, I don't know, that's a whole different conversation with COVID and behavioral health drugs and, you know, like how people have emotionally reacted to the last three years.

49:32But when you look at it for insperity, it's probably bad right now because, you know, as long as these companies have a duopoly on these drugs, the costs will probably be high. But that can only last for so long. Eventually, there will be competition. Eventually, the cost will go down. Eventually, it'll be like Viagra, where it goes from$88 a pill to whatever,$2 a pill. Maybe it was a bad quarter for insperity. Maybe that continues for a little bit while they're still expensive. And then eventually, it'll get better. But when you think of it from, let's say, Cigna or UnitedHealthcare, Cigna on their earnings call, they said, you know, GLP ones are definitely top of mind for many of our clients.

50:09There's been a meaningful uptick in utilization. and essentially what they said was you know there's a continued interest in behavioral solutions you know these insurance companies they will like pay for you to get a gym membership or they'll pay for you to get a meal plan or something and the success rates of those things are dismal like absolutely awful right and you know it doesn't work and insurance companies are stakeholders in global health right and they're really good at anticipating how much it's going to cost and making sure, you know, that they make more money than what's what it's going to cost.

50:45But as an epidemic, this is still like a relatively new thing. The obesity rate has never been 42 percent before. And so what do we how can we really accurately model what that's going to look like in 50 years? I mean, you know, maybe if it continues the way that it's going on abated, I think that ultimately, you know, health insurance that it's going to be a significant hit. So what you're seeing is these drugs, drug companies essentially going on these data campaigns, which is, you know, we're going to show you not just that it results in weight loss. We're going to do a study and a clinical trial on every single one of the beneficial effects of losing weight.

51:22Right. We're going to say, oh, obstructive sleep apnea, hyperlipidemia, hypertension, heart disease, type two diabetes, knee replacements, all of this stuff. And then eventually it is for Cigna or for UnitedHealthcare. it is going to be, they're going to do what insurance companies do. They're going to negotiate. They're going to push down the price. There's going to be pushback. There's going to be what gets covered and what doesn't, especially after Monjaro gets approved for obesity. But at the end of the day, the thing is they are basically going to have to do a cost-benefit analysis. And there is no way in my mind, I think really, even if they were paying 150 % of what Lily's charging, didn't negotiate at all over the course of the next 20 or 30 years, they would probably make money like they would probably be a better situation than it would be without it.

52:15You know, not to get too like insanely off the rails. But again, it's a podcast. So this whole thing is a thought experiment. So let's do it. Let's entertain some people. Right. Why shouldn't the government pay for this? Well, you mentioned that the Inflation Reduction Act is going to reduce the cost. This should be Biden's re-election. He's like, hey, I signed the bill that's going to make that. Ozempic for all. Ozempic for all, yeah. Seriously, this is a good idea. Let's look at this, right? We just had the biggest public health experiment ever. We had COVID, right? Does anyone know off the top of their head how many people COVID?

52:50That's not a fact that I have handy.

52:54Right. And how many people, what was the all-cause mortality of like COVID in like annually during like the peak of the epidemic. I don't know. It was probably high. But what I'll tell you is it probably was similar to how many people are going to die of obesity this year. You know, I don't want to like like speak without facts in front of me. But I would say, you know, if if someone wants to go look that up and, you know, whether it's how many people die of obesity this year or how many in five years, I would say that they are probably comparable public health crises. And also in terms of the impact on the economy, obviously nothing can rival shutting down the entire economy and, you know, having a lockdown.

53:37But if you look at it from an acute versus chronic perspective, you know, if obesity is going to cost us a trillion dollars this year in indirect costs and we're running at a trillion dollars a year, I mean, over the next 10 years, like what it just seems like something where it let's say that, you know, Lilly and Novo and all the other companies that eventually joined the fray, that they're effective in proving that the side effects are moderate and that the overall benefit is sustained and it's good. Why would the government not cover it? Right. Like if they're if they'll cover COVID vaccines, then they should probably cover this, too, especially if it has a 20 percent reduction in like heart attacks.

54:15I mean, well, I would never overestimate America's ability to make bad decisions when it comes to public health care. But that's a good point. But James, that was a really fun conversation. Absolutely a blast to have you on and go through the transcripts sort of in real time while we're talking to you. That was great. Absolutely. And, you know, if you want to learn more, you know, I've been writing about this since June on Citrini Research dot com. I go pretty deep into these. I did one on A &M. No, it's a great read. Yeah. Oh, you read it? Come on. We do a little. Believe it or not, there is some.

54:52I read it on the subway this morning while coming in. I do real prep for this job. I sent it to you like 12 hours beforehand, and I know it's like, you know, 20 pages long. So I would have forgave you. All right. Well, James, thanks so much for coming on Outlots. Appreciate it. Thank you so much for having me, guys. Thanks, James. That was a pleasure.

55:23All right. Well, Joe, I, for one, look forward to the svelte future of publicly funded weight loss drugs. I mean, I totally like why not? If all the things seem to be true about this, what many people seem to believe. And, you know, it's like James is like totally right. Like you see a lot of people like poking. They're like, there must be some catch here. Right. There must be. It's going to melt your insides or it's going to do something. Maybe one day. You never know. But right now, anything I read about the side effects never seem like that compelling or anything. I just point out the class of drugs for a while.

55:55It kind of feels like potentially like a legit miracle drug, right? Like it's kind of wild. Well, I think he makes an excellent point about the tradeoffs, right? And at some point, it might be cheaper for an insurance company to just provide this drug rather than treat someone for diabetes or heart problems or sleep apnea or whatever else for the rest of their lives. The other thing I was thinking throughout all of that, you know, I initially came into the conversation thinking like, oh, well, if everyone's consuming less, maybe that's deflationary. But now I'm going back to that price over volume theme.

56:27And James brought it up as well, which is, well, if you're Wendy's and people just aren't buying as many cheeseburgers, then maybe you just raise your prices to offset it. Could be. I am. I mean, there's all kinds of like other things that we could get into. And so another thing, and I saw someone on Twitter say this, they're like, well, the snack companies put even more salt and other addicting type of like ingredients to counter this. To offset it, yeah. So that the people who aren't taking the drugs buy even more in the future. Like they're not going to give up without a fight if there's some drug that causes people, you know, like everyone's going to like try to like find some way.

57:04We didn't talk about gyms really, but I wonder like one way of thinking is maybe it's bad for gyms. But on the other hand, like if you want to show off, that's exactly right. If you feel more confident than maybe like, you know what, I'm ready to I don't mind being seen at the gym. All kinds of interesting questions. Like I like the idea of like, you know, match or hinge is a buy or is like a winner here. So that was a very fun thought experiment. And it was fun in the context that he knew so many details. So it's like also kind of real. Not just. Yeah. And I'm going to spend, I think, the next like two hours or so just going through some of the earnings transcripts and seeing what people are saying about this.

57:37Because I hadn't realized that people were already actually talking about it. Well, so I think the reason I didn't realize it is because I was searching. It was Zempik. It's just like the thing. You just search GLP. But they're all searching. You just search GLP and then tons come up. And so it's really interesting. I mean, it's a huge focus on a lot of these calls just from looking it up. All right. Well, fun conversation. Shall we leave it there? Let's leave it there. OK. This has been another episode of the All Thoughts podcast. I'm Tracy Alloway. You can follow me on Twitter at Tracy Alloway.

58:06And I'm Jill Weisenthal. You can follow me on Twitter at The Stalwart. You can follow James Van Galen on Twitter at Citrini7. Also check out his research. Follow our producers, Carmen Rodriguez at CarmenArmin and Dash O 'Bennett at DashBot. And all of the Bloomberg podcasts can be found under the handle at Podcasts. And for more OddLots content, go to Bloomberg.com slash OddLots, where we have a transcript, blog, and a newsletter. And we don't have a pharmaceutical channel on there. Maybe we've got to add a medicine and health one, but check out the Discord. One of my favorite places to hang out on the internet.

58:42Other OddLots listeners are there talking 24-7, discord.gg. And if you enjoy OddLots, if you like listening to these types of conversations, imagining a world without obesity, then do leave us a positive review on your favorite podcast platform. Thanks for listening.

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From the publisher

There's a new class of weight-loss drugs in town. GLP-1 medications including Ozempic, Wegovy and Mounjaro were created to treat diabetes but have since been found to suppress appetites and induce substantial weight loss. It's a big deal for the companies which make them, with shares of Novo Nordisk and Eli Lilly all soaring in recent weeks. But the drugs could end up having a much broader economic impact too. On this episode, we speak with James van Geelen of Citrinitas Capital, about the second-order effects of effective weight-loss drugs. He talks us through how he's evaluating the potential of the new meds and how he approaches possible 'mega-trends' like GLP-1 or AI.

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