Big pharma are running a MASSIVE global marketing campaign, trying to convince us that weight loss drugs are A Good Idea. I’m looking at you, Novo Nordisk! Join me and my extremely outraged guests Dr Fiona Willer & Ragen Chastain, as we revisit the dastardly history of weight loss medications. Past experience has brutally demonstrated that far from improving human ‘health’, these drugs have proven to be (spectacularly profitable) human disasters – most of them have been removed from the market for harming or killing people. Big pharma cares about profits, not lives. Have we learned anything from the sins of the past? Frighteningly, it seems like history is about to repeat. Don’t believe the hype – do not miss this two part deep dive into the devious and deadly world of weight loss drugs!
Click below for the Show Transcript & Shownotes
Louise Adams 0:12
Welcome to all fired up. I’m Louise your host and this is the podcast where we talk all things anti diet. Has diet culture got you in a fit of rage? Is the injustice of the beauty ideal getting your knickers in a twist? Does Fitspo make you want to Spitspo? Are you ready to hurl if you hear one more weight loss tip? Are you ready to be mad loud and proud? Well, you’ve come to the right place. Let’s get all fired up! Hello diet culture drop outs, it’s so nice to be back. Welcome back to all fired up. I haven’t gone anywhere. I’ve just been deep down a rabbit hole researching for the following two episodes, diving into the world of big pharma Have I got two cracking episodes for you to help you celebrate the festive season – diet culture as you know is in its high point/low point right now. And I’m super cranky about Big Pharma. So for the next two episodes, you’re going to discover exactly why I am so mightily fired up. But first, I want to talk about some free stuff. If you haven’t already downloaded this, I have a free ebook written by me and the wonderful Dr. Fi Willer, anti diet dietitian and guest in today’s episode, this ebook is called everything you’ve been told about weight loss is bullshit. And it is busting the top 10 diet myths that are floating around our culture like bad smells. If you are looking for a resource to help you dive into the science of why weight loss efforts are ineffective and harmful. Please go to untrapped.com.au it will pop up you can download it, you can give it to friends, family, medical people, you can even pop it in people’s Christmas stockings if you feel like it. But it is wonderful. It is completely free, more free stuff. If you are struggling at the moment with all of diet cultures messaging about pursuing weight loss, and you’re finding it really hard to feel okay in your body. Look no further than my befriending your body free e-course it is available on my Insta account, which is untrapped_au. And you can click on the link to get the free e-course. This helps you learn self compassion skills which in my opinion, learning the skill of self compassion is your single mightiest weapon in befriending your body and keeping the dragons of diet culture at bay. So what you get is a 10 day email series. So you get an email from me every day, talking you through different aspects of self compassion, and relating to your body helping you to kind of come home to your body because let’s face it, diet culture is a massive disconnector. So those are the free things. I want to send a massive shout out to the lovely UNTRAPPED online community. UNTRAPPED is my online anti diet course and group community we’re about to go on retreat, which is so exciting because this has been booked since 2020. And finally, after years of waiting, we finally get to connect in real life. I’m very excited. If you are looking for a community for really a deep dive into unpacking your relationship with food with joyful movement with your body, then look no further come and join us at UNTRAPPED so you can find out more about the community and the course untrapped.com.au We’d love to have you and who knows, maybe next year you can come on retreat with us. Okay, so to today’s episode, as I said, I’m completely fired up. I’m wild and outraged, completely and utterly outraged about Big Pharma and the stranglehold that it has on diet culture, especially right now. I have two wonderful guests for you today. The first is Dr. Fi Willer, anti diet dietitian and aforementioned co author of the everything you’ve been told about weight loss is bullshit free e-Book. Fi is an academic and lecturer, a speaker, prolific writer and just a brilliant brain a complete skewer-er of weight science. If you haven’t already gone and visited her website health not diets, please go do so. If you’re a health professional, she’s got so many resources on training and various aspects of learning more about weight science and how to understand it, unpack it and push back against weight bias. It’s terrific. She also has this really good podcast called unpacking weight science and she has a really good episode on weight loss drugs, which I highly recommend if you’re really interested in today’s topic, go listen to Fi’s specific podcast on weight loss drugs because it is sensational. So I’m very happy to talk to Fi. And my other wonderful guests today is Ragen Chastain, who has been on the show before I’m so excited that she’s coming back. Ragen is from dances with fat. She is a speaker, writer, dancer, marathoner, health coach, and just all around awesome human. Ragen has written some really fantastic blogs on the topic of weight loss drugs and the influence of big pharma in our culture right now, I strongly suggest that you go and find her and follow her and follow her newsletters that come out on this because it’s just absolutely brilliant. So we have a terrific two parter coming up for you. The first is on weight loss drugs and the dastardly history of what they’ve been doing to our planet since the 1990s. And our second one is unpacking the octopus of Novo Nordisk, and its current mission to soak the planet with diabetes drugs for weight loss. Now, there are lots of ‘O’ words in the next two episodes, because it’s kind of impossible to talk about this without using O words, but make it very clear to all my listeners, I do not agree with the term ‘obesity’, I think it is an unnecessary pathologizing medicalizing word that big pharma are using to create a disease from diversity, which in my opinion, is a crime. But just so you know, there are lots of O words, something else I need to say before we get started with the next two episodes, I guess it’s a disclaimer about absolutely no judgment here, everybody, on All Fired Up I’m talking and ranting with people around the world about the influence of diet culture, and its constant pressure on all of us to become smaller. The diet drug industry, weight loss drug industry directly target fat people. And as we know, weight stigma impacts larger bodied people in a different way to the impact that diet culture has if you’re a thin person. So I’m presenting this episode and the next one, in an effort to illustrate the pharmaceutical industry’s influence on the very way we think about body size, I have no judgment towards people who might be being treated terribly, or being denied medical intervention because of a BMI range. And I understand the pressure that you’re under, to shrink your body in order to access certain things. So I have no judgment towards people who make these choices to take these drugs. That’s I’m not intending to do these episodes to judge anyone except the industry itself. But I do believe in informed consent. I do believe that a lot of the time, we’re not told the full background story. And we don’t get to dive into the research as much as we’re going to today. I’m a big promoter of critical thinking. And I think that we need to kind of see, evaluate and make up our own minds about what we’re going to do with our bodies, given what we know about the companies and the influences that are shaping this. So it’s really good to be back. And I hope you enjoy the show.
Diet culture constantly sells us diets or lifestyle changes, introducing physical restriction, but weight loss drugs take things to a whole new level, taking pills or injecting drugs into our bodies, impacts directly our physiology, our organ function, our cardiovascular system, our endocrine system, and brain function. This is serious stuff. We’d love to think that because drugs are regulated and prescribed by doctors that we’re protected that we’re safe. And if you want to continue to think that I might advise you to hit pause right now, because the history of weight loss drugs will seriously burst that bubble. So before I introduce my wonderful guests today, I’m going to tell you a little story about the disastrous history of Fen Phen, one of the earliest weight loss drug crazes, which really highlights just how much drug companies who profit from selling weight loss drugs are influencing things from behind the scenes. We’re going to head back to 1979 to meet Lou Lasagna, a physician and Chairman of the University of Rochester’s Department of Pharmacology and Toxicology, a freshly opened university department which had been crowdfunded by the pharma industry. In 1980 Lasagna had written one of the first public treaties on his idea of obesity as a chronic disease. Thanks for the fat phobia Lasagna! At the time, drug company AH, Robins drug fenfluramine, which was brand name condeming was a pretty lackluster diet drug on the market. Fenlfuramine is a serotonergic anti seizure medication, which has an anorectic or appetite reduction effect and it comes with a full on startling list of side effects including hives, difficulty breathing, swelling of your face or lips tongue or throat, mood changes, anxiety, panic attacks, trouble sleeping, impulsive behavior, irritability, agitation, hostility, aggression, restlessness, hyperactivity, worsening depression, thoughts of self harm, chest pain, panic, heartbeats, shortness of breath, blue colored skin or lips, swelling in your legs, unusual tiredness, weakness, lightheadedness, loss of appetite, worsening sheet seizures, blurred vision, tunnel vision, eye pain, pounding in your neck or is nosebleed hallucinations, fever, sweating, shivering, fast heart rate, muscle stiffness, twitching, loss of coordination, nausea, vomiting, and diarrhea. Fenfluramine was developed in the early 1960s and was first introduced for medical use as an appetite suppressant in France in 1963. And then it was approved in the US in 1973. And according to legend, Mike Weintraub who was one of Lasagna’s research protegees, was stuck in an airport due to a snowstorm. And he was just about to present a conference paper about diet drugs. And he began thinking about what he thought to be the biggest drawback of Fenluramine -sleepiness – and he wondered what would happen if people took a stimulant like another diet drug? Something like phentermine. Eureka. phentermine was at the time approved as an appetite suppressant in the US, and it had been since 1959. phentermine is primarily a norepinephrine releasing agent, and it also induces the release of serotonin and dopamine. Basically phentermine kind of acts like speed, like it’s an upper. Lasagna floated the idea of doing a research study combining the two drugs phentermine and fenfluramine, Fen Phen, to the AH Robins company and according to a December 1979 company memo, the pharmaceutical division believed that ‘a positive outcome of this study will produce a significant increase in fenfluramine sales’. Note the complete lack of thought here about any potential harm, which is interesting, because in the mid 70s, the AH Robin’s company had encountered more than 300,000 lawsuits launched against them because of their Dalkon shield birth control device, which was found to cause pelvic inflammatory disease, infertility, spontaneous abortion, septicemia, and death. As an aside, the dalkon shield disaster basically sent AH Robins broke and then they were acquired by American home products. The pharma world is full of stories like this. One company falls on its sword because of lawsuits, and then they get snapped up by a big company. It’s Game of Thrones, so eventually, Weintraub was given grants to investigate his brilliant drug combo idea. These were officially funded by the National Institutes of Health’s National Heart, Lung and Blood Institute. But there was also a lot of money thrown in from AH Robins. According to Alicia Mundy’s book ‘dispensing with the truth’, the drug companies would suggest studies to get co founded by the NIH, and then the government would come up with a grant because studies that are funded by NIH grants look a lot shinier and more plausible than the ones funded by drug companies. And to this day, we still don’t know how much money was provided by the drug company. But Weintraub wrote a lovely note to his patrons, as his study drew to a close which says, ‘without your assistance, and that of AH Robins, the study could not have been undertaken on the budget that we had received from the National Heart, Lung and Blood Institute’. What a nice guy. So he did his study, how effective was Fen Phen? Well, at 34 weeks, the trial showed a 15% weight loss, but long term results at three years later, showed that not only half of the participants had dropped out, but also that they were regaining weight. Look, what is really striking about these studies is that this drug combination had never been tried in humans before. Normally, this kind of wild experiment would at least be tried on animals before throwing people into the mix. It also concluded that this was safe. In spite of about a quarter of participants reporting adverse events. Weintraub’s study ran for four years from 1983 to 87. But weirdly, it just wasn’t published straight away. Or maybe not weirdly, because this combo of drugs was not approved for use by the FDA, and drug companies were prohibited from promoting the off label use of drugs but then in 1992 It did get published as a supplement in the Journal of Clinical Pharmacology. Supplements are usually paid for by sponsors, aka the drug industry. Many years later, during the court cases in the aftermath of the fen phen disaster, Weintraub admitted that industry money had paid for the supplement to publish the article. Sadly, he couldn’t remember which company had paid him ah, industry money, where would we be without you? So, once word got out about fed phen via a press release from the University of Rochester, it went wild. In February 1995 fen phen was featured in women’s magazine Allure and then in Reader’s Digest. It was never technically approved by the FDA as a combo drug itself but the doctors were prescribing it off label left right and center. Doctors began openly advertising the drugs in newspapers on the internet, and it literally walked off the shelves. storefront clinics even popped up in shopping malls. Jenny Craig was giving it out to their clients and Nutrisystem were also offering it to their customers. Unsurprisingly, demand was just unbelievable. From a beautiful beginning, concerns really quickly appeared internationally. Pondermine domain was on the market in France. And a French study called the International primary pulmonary hypertension study found that taking Pondermine and or its sister drug Redux increased the risk of primary primary pulmonary hypertension by 10 times and with longer duration of use, this risk went up even higher. primary pulmonary hypertension is not fun. It’s a type of high blood pressure that affects the arteries in the lungs and in your heart. It’s incurable and can lead to death. If it’s not picked up quickly. It drastically impacts life expectancy. In August 97 an article in the New England Journal of Medicine by the Mayo Clinic revealed another 24 cases of unusual valvular disease in patients taking fen phen as a result of these findings and another 75 cases of heart valve disease reported to the FDA, both Pondermine and Redux were withdrawn from the market on September 15 1997, but not before the company American Home Products had turned a profit of $200 million.
So that’s quite a story to kick us off with Am I right? Are you fuming? Well, believe it or not, that is just a taste of what is to come in this episode. Let’s go and meet our two guests for this week who have even more torried tales to tell. Welcome to the show. I’m so happy to be here with Dr. Fi Willer and Ragen Chastian, we’re all here because we’re fired up about weight loss drugs, the world is at a point lately, where we seem to be really embracing drugs and weight loss, drugs, pharmacotherapy, whatever we want to call it, basically Big Pharma solutions to larger bodied humans. And the marketing at the moment of this approach to larger humans is it’s everywhere. And I really wanted to do this episode, because we need to just hold up a second and take a look back at what weight loss drugs have really done to the planet and figure out from there, if what’s going on is something that we can truly trust. So we’re going to have a really deep dive in this episode into all of the different weight loss drugs that have been approved since the 1990s. And tell some stories and get some facts on what has happened because the history seems like it could repeat itself. Ragen cann you talk a bit more about what you know about fen phen?
Ragen Chastain 18:47
Sure. So when it came on the market in 1992, originally, it started as an off label prescription. And it was being prescribed based on a four year study that only included 121 people. And four years, as we’ll find as we go down these other drugs is actually a pretty long time for a study to happen. But 121 people is such a tiny group, but still by 1994. The company already knew that there were 41 cases of valvular heart disease and pulmonary hypertension. They only reported four of those to the FDA. Whoa, yeah. So this is a problem in the states of like how we gather data, like if the company that’s profiting off the drug is the one responsible for reporting the issues, then this is a repeated problem in the US, but they don’t have a big incentive to report that honestly. So they reported these 4 by 1995, the drug had become super mainstream was in fashion magazines and all over media, and it’s estimated in 1996, that doctors wrote about 18 million prescriptions. Oh my god. And then the next year and in 1997 research started to show that about a third of the patients had serious side effects, and the company eventually had to pull the drug and paid billions in settlement, which again, uncommon that they actually had to face consequences to their actions that were serious to the company’s bottom line. But obviously, that those billions will never return the health, the lives of the victims of the drugs, which were predictable pretty much from the beginning, in order to get on board with this idea of diet drugs as a quote unquote, treatment for people existing in higher weight bodies, you have to believe it’s worth risking their lives and quality of life to make them even a little bit thinner. The only way that somebody could justify this, these are all of these drugs have incredibly serious side effects. And those are considered acceptable risks.
Louise Adams 20:35
I have no words. Well,
Ragen Chastain 20:39
I have a lot of them, but they’re swear words. So
Louise Adams 20:41
yeah, swearing is welcome. I read that the drugmaker wyeth had set aside $21 billion to settle all the litigation or the lawsuits coming out of fen phen, which was only on the market for five years, right? Oh, my God, like that is like a catastrophic human cost.
Ragen Chastain 21:02
And it caused so the original company that manufactured it was called American home products. And so they actually like it sort of it essentially put them out of business. But they just went ahead and were acquired by another company as good as pharmaceutical companies here do, but American Home Products itself, Phentermine was sort of the end of them.
Louise Adams 21:19
Well, that’s not sad. In my
Ragen Chastain 21:22
by my belief,
Fi Willer 21:24
it was only five years that it was on the market, it really felt like it was a lot longer than that the kind of the fallout and the reputation and that you know that this this is now part of weight loss efforts. History, I guess, five years is such a vanishingly short time, really to have been available, but to have done so much damage it wreaked havoc.
Ragen Chastain 21:44
And I mean, in a testament to how desperate people are to lose weight because of how much they’ve been misinformed that weight loss is the only way that they could possibly pursue health. And because it is, at this point, one of the only ways to avoid weight stigma. People were clamoring for the drug and trying to get it illegally in the states trying to get it from other countries, like people were still even knowing that this drug was killing people and that it had been pulled people were still trying to acquire it. That’s not
Louise Adams 22:09
surprising. It’s devastating. But yeah, not not surprising. I mean, what is surprising that it was taken off the market, because the statistics were so convincing, and the lawsuits were piling up. I think that’s the pattern here with the big pharma companies. It’s it’s getting things onto market really quickly without properly looking at long term impacts. Ignoring danger signals until it’s way too late, and only taking stuff off the market when they’re really like their backs are against the wall in terms of profit. This is not actually about caring about humans. So next one we want to talk about is Meridia or sibutramine, which is from Abbott. And this is it’s an SNRI. So it’s a serotonin, norepinephrine reuptake inhibitor. So in humans, it inhibits your reuptake of norepinephrine, it
Fi Willer 23:00
just can’t say that well, norepinephrine.
Louise Adams 23:05
Thank you. And I’m gonna try and say it again. And I was so different. Yes, serotonin and dopamine. So it increases the levels of all of these, apparently that helps increase satiety. And the serotonergic action is thought to influence appetite. So it’s similar in action to a tri cyclic antidepressant. And this was approved in 1997 for weight loss in the United States and taken off the market in 2010. So that’s 13 years on the market. That’s a long time, and especially 1997, which is around when fen phen, and that whole disaster was unraveling. It came off the market in 2010, after what they call a post market trial. So this is after it’s been released on to actual humans. They do longer term trials, they actually then find out what’s the impact of this on human bodies on it’s called the sibutramine cardiovascular outcome child or scouse on it demonstrated a 16% increase in cardiovascular events, basically, heart attacks, strokes, cardiac arrest thing that really awful things like that. So people were having really bad heart problems, and that’s why they took it off the market. It was in Australia, Canada, China, Europe, Hong Kong, India, Mexico, New Zealand, Philippines, Thailand, UK, and the US. And it do get withdrawn here in Australia, I think in 2010, but it’s still available in some of those countries that I’ve just read out, which is pretty hideous,
Fi Willer 24:41
so strange that it has not been it really wasn’t marketed in the same way that the the more recent ones or fen phen was marketed as well. Much less aggressive, which is interesting.
Louise Adams 24:53
Yes, I guess the marketing the marketing is less aggressive, but the resulting death from taking it is pretty much the same.
Fi Willer 24:59
Thank you. Yeah, but I mean, you know, it’s off brand for Big Pharma to not completely drench the community in marketing for their drugs.
Ragen Chastain 25:09
We had a ton of marketing in the states commercials and stuff, like kind of chubby women walking around with plates, but not eating the food kind of thing. So
Fi Willer 25:20
in Australia, it’s illegal to direct market to consumers. But I guess it was just the awareness in the sort of medical field and in the health field, because we would get the ads didn’t seem as loud, basically,
Ragen Chastain 25:30
yeah, the thing that strikes me about this, and as we talk about these drugs, like in 44 weeks, the average weight loss at most was 3.8. kilograms. Oh, right. So that so for us here, and that’s with constant therapy, as opposed to Intermittent. So in the States, that’s like eight and a little bit less than eight and a half pounds, so we’re risking heart disease for eight and a half pounds an amount of weight I could lose right now with a loofa, and a haircut, risk heart disease to make that happen. And this is what consistently, we are being asked to risk our lives and quality of life and health, to lose a couple pounds, which makes absolutely no sense the idea of these risk benefit analysis, analysis is really off kilter.
Fi Willer 26:12
It is ridiculous, because the rationale for recommending weight loss is these long term outcomes. And if that were true, they would actually have to show long term outcomes with these drugs. But really what they’re showing with such short term sight here oversight is that it really was never about health. It was always about appealing to people’s aesthetic proclivities, or trying to really push people to believe that that’s important under the guise of this health message. There’s a complete disconnect with intention and outcome here.
Louise Adams 26:43
Actual health. I mean, one of the things that, you know, obesity Inc, always bang on about is that being larger is bad for your heart. And Hello, excuse me? Is anyone looking at the impact on hearts for tightness, right, but that, you know, when I was researching for this episode, it’s stunning how the old clinical trials and research basically ignore health outcomes, focusing only on this like, secondary marker of weight reduction. And no one knows. I mean, it’s staggering to think that no one was really interested in the impact on heart until after it came out, and then found something much worse. Just absolutely astonishing.
Fi Willer 27:27
Such a bolted on assumption that weight is tantamount to health status. Proxy, yeah, absolute proxy marker. And in fact, now it will, particularly in the US where higher weight is deemed a disease status. And so that means the goalposts has completely shifted just over there. There’s not even any pretense of risk, factor them anymore over there. Whereas in Australia, higher body weight is not classified as a disease state. I mean, it really isn’t, it shouldn’t ever be and what happened in the US is not right. But when you shift goalposts like that, from risk status, like population, epidemiological statistical associations, to an individual viewpoint to the one single data point, at which point that population started becomes actually completely irrelevant. That’s what we’ve done here with weight status to the detriment of humanity, really.
Ragen Chastain 28:22
And it should be noted that in the States, the the AMA declaring obesity, quote, unquote, to be a disease, the whole belief that being higher weight is now a quote, chronic lifelong health condition was in extreme lob- in response to extreme lobbying by the weight loss and diet industry, including their creation, essentially, they’re taking every page they can out of the Purdue pharma oxycontin playbook. Yeah, and we’re seeing that we’ll talk about that I’m sure in the episode about wegovy and wegovy depending on where you live. But this is a situation where this wasn’t it’s not justifiable by the data. It simply doesn’t make sense there you can have two people have the exact same weight with very different health statuses people two people have very different weights with the same health status. So using weight as a proxy for health is deeply problematic. But considering simply existing at a higher weight to be a disease, regardless of actual any kind of metabolic or other health measurement is not scientifically justifiable. I mean, it’s it’s to understand that
Fi Willer 29:21
and the way that they tend to explain it these days is that a disease has to have issue with physiology the actual function part of a biological system, whereas BMI weight of course the diagnostic test for obesity is simply standing on the scales and being your home. So that’s a anthropometric test. That is a test of anatomy. It’s not a test of physiology. It’s like we’re using head circumference as a disease designator, where sure head circumference would there’s a range of head circumferences, and sometimes being sort of at the further ends of the ranges can indicate that there might At least be some kind of issue there. But we don’t stop at saying that the actual head circumference is disease we go, oh, let’s have a look at what might be going is there some sort of genetic issue, is there, you know, what’s happened with this person, whereas when we disease-ify, body weight, it stops a conversation, it stops investigations that stops curiosity about what might be going on for that person. It may not be anything, it might be something but stopping there and causing and, you know, treating that like a disease, not treating, but I mean, like approaching that status as if it’s a disease itself means that we’re doing bad science we’re doing bad health care, we’re doing bad, bad, rational thinking, like it’s just up in that conversation. And that’s not fair to anyone.
Louise Adams 30:39
No, but that’s exactly why we’re here, right? It’s disease-ifying body size leads to the pharma industry profiting hideously from doing horrible things like Ragen’s saying, In the name of health. The next one I want to talk about is Ali or orlistat or xenical, have you heard of this one?
Fi Willer 30:59
I’ve just noticed Lou, this is the one that I called fat shat.
Louise Adams 31:06
Okay, so this was FDA approved in 1999, on prescription in the States, and then in 2000, from 2007. In the States, it’s been over the counter. And in Australia, you can buy it over the counter it No, no matter what size you are, you can go to a chemist and get some fat shat. So can you describe to us what this wonderful health enhancing drug is Fi?
Fi Willer 31:28
So fat shat, or orlistat is a medication or drug that you take when you eat. And what it does is binds up the fat in the food that you’ve consumed so that your body can’t get to it and break it up and absorb it inside the body. But of course, of course, the gastrointestinal tract is just a tube we’re kind of doughnuts humans, because the gastrointestinal tract is still the outside of our body technically. So the orlistat or fat shat means that that fat from the food is it stays in your gastrointestinal tract. Now, in our large intestine, our bowel, that’s the last bus stop before exits, that is where water is reabsorbed from what’s left of what’s been digested. Your gut bacteria mostly lives in the large intestine. And it’s poring over what’s left kind of a bit like a rubbish dump, with the last bits of it being processed, energy will be created, gases created, that’s where fats come from. So there’s a whole lot of stuff going on in the large intestine, but it is not, it’s not used to having fat fat is usually absorbed much further upstream in the small intestine, that’s where that happens. So when there’s fat, still, in the large intestine, those bowel back to bacteria become different kinds of populations. So we’ve had since different kinds of bacterial action, different kinds of farts, if you want to put it that way, different kinds of populations are not necessarily healthy either. So there is a microbiome story in this as well. But really, the lived experience of taking this drug is actually the most important thing, because when you’ve got fat in the large intestine, your butthole is not really able to keep things in as much as it otherwise is able to, because things are a lot more liquidy. So one of the main side effects of this drug is leakage. And do you mean to mean like, sharting? I mean, sharting, I mean, oily. When you’re when you’re not expecting it, to the point where Ragen, just let me know, prior to this episode that on packaging in the states that had take us take a pair of extra underwear with you, when you take this, just in case, I mean, have you that’s a pretty strong warning to not take the drug, right? So the assumption there is that because it’s not making into the body, that that will cause an energy deficit, and then that person will lose weight. But actually, the body’s pretty smart and appetite centers are such that they realize when they haven’t absorbed enough energy, and so it actually just increases the drive to eat a bit more in order to meet energy needs. So it’s no effect. Plus, you can poo your pants you know, unexpected times. So, fantastic, fantastic outcome for that one. Get yours at any pharmacy near you.
Louise Adams 34:13
And this one hasn’t been recalled.
Fi Willer 34:16
It’s not dangerous. It’s ridiculous. Basically,
Louise Adams 34:20
it’s ineffective and smelly. And yeah,
Fi Willer 34:23
thankfully, I mean, it’s action it stays in the gastrointestinal tract, right. So there’s nothing actually makes it in the body. There’s no effect on heart valves or liver function or any kind of metabolic function does not do that. It’s really a kind of physical effect. If you want to put that rather than a biological or chemical effects really, a bit has to be chemical, but if you can think about it as a physical effect, just like a sponge, basically. So in terms of long term health risks, it’s low but Why would you waste your money?
Louise Adams 34:51
Well, this says side effects include back pain, sinus infections, soft stool, abdominal abdominal Faecal urgency (don’t snort it!) Uncontrolled anal seepage, fatty – that’s it I forgot the word. Fatty, oily, stool, spontaneous bowel movements, kidney stones, severe stomach pain, liver disease, pancreatitis and kidney stones. So not without side effects.
Fi Willer 35:19
The pancreatitis is from over activity of the pancreas creating the secretions that it tries to get rid of the fat in the large intestine, all the emulsifying juices basically. So that’s where that will come from. I mean, we’d have to take it for a long time to have those effects. But like, honestly, don’t take it for a long time. Yes, exactly. I
Ragen Chastain 35:41
May I mention the the approval process because this has got to be one of my favorites. It was approved based on a six month study, and the study claimed that quote, most people lost five to 10 pounds over six months. Now, what’s important to understand is they only started with 19 people. And by the end 10 had dropped out. Oh my god, nine people lost four to six pounds more than the people who took a placebo. This is the entire and this drug was approved based on this. When they finally did further studies, they found that people lost about 5.7 pounds more in a year than those who only died in an exercise and it sounds like a decent amount of that kinda leaked out of them. Yeah, it’s like I always want to be like, when I talk about this, I want to make sure I’m never ever shaming people with fecal incontinence. No, right? That’s a real thing. There’s no shame in that. But to take a pill that causes fecal incontinence in order to lose maybe five pounds with no no indication that you would keep it off for more than that year. That is where I have a huge problem. It’s just one of the many places
Louise Adams 36:44
Yeah, oh, good lord. Where are we? This is where it’s wild, isn’t it? This is This is wild. So that that is one hell of a clinical trial you described their Ragen, human safety at its finest just looking looking at that kind of impressive stuff.
Ragen Chastain 37:02
When reading these trials I always think like why did I work so hard in these research methods classes, like I could have just gotten a job for, you know, the diet industry doing exactly the opposite of what I learned it would have been great.
Louise Adams 37:13
Okay, the 90s. Yeah, wild west when it came to, like, easy to get a clinical trial, obviously approved to get the drug on to the market. So we’ve talked about three weight loss drugs so far, and two of them were withdrawn from market only, only the fat shat one has survived. And then there was a really quite a long gap in approvals for weight loss drugs, which was, you know, a pleasant moment for the planet just in the wake of the devastation of Fen phen because literally so many people died and the publicity was awful. So between 1999 and 2012, the FDA didn’t approve any more weight loss drugs, they really lost interest and figured it was a stupid idea. But then you notice that are in between 2012 and 2015, a whole kind of pile of new weight loss drugs got approved, so specifically Belviq, Qysmia, Contrave Saxenda and now of course recently, wegovy. So what on earth is going on? I read this amazing investigation by the Milwaukee Journal Sentinel, they did an investigation between 2010 and 2015. In the United States, the drug companies put more than 60 million US dollars into lobbying and paying off the FDA and Congress and to physicians and to medical organizations. So in the month before 2012, when things started to get approved again, officials had lots of meetings with members of the obesity industrial complex, so drug companies, weight loss companies, medical societies, and the weight loss academic and this group, you’ll never guess even produced a consensus report, which waxed lyrical about weight loss drugs and how much benefit they could be to societies. And you’ll never believe it. These meetings were funded by the drug companies. In addition to these meetings, a huge amount of money has been poured into multiple pipelines by all of the drug companies all with the aim of getting their drugs approved. So the drug money is being used to pressure concrete Congress to sponsor the medical societies who dutifully began to release obesity treatment guidelines, and then these societies are spending huge amounts of cash themselves lobbying Congress with similar messages. So for example, in America, the Obesity Society received $393,000 from drug companies between 2011 and 2015. And in November 2013, the Obesity Society issued a guideline urging doctors to diagnose and treat obesity at every medical visit in 2013. The endocrinologist Association got $3.2 million from the obesity drug makers. And in 2014, the American Association of clinical endocrinologists released new recommendations for diagnosing and treating obesity. And that group alone has spent nearly half a million dollars lobbying Congress. So in 2010, the FDA rejected two new diet drugs because they were concerned about cardiovascular risks. Not surprising, given the recent history, because they just removed Meridia from the market. But then the Senate stepped in in 2011, and had all these meetings with the drug makers and Big Pharma. And then within six months, you’ll never guess a new diet drug started to get approved. So first, there was Belviq, which was approved in 2012. And then Qysmia was approved, and both of them had separately been rejected by the FDA, just two years earlier. And then Contrave, which had also been previously rejected by the FDA got approval as well, what do we think of this?
Ragen Chastain 41:00
Yeah, it’s so Belviq is one of the drugs that we see a similar thing happened, where the risks that showed up in the trial are the risks that ended up getting it pulled from the market. So it was not like these things were not predictable. And this is, again, a consistent thing with diet drugs. They also Belviq did a thing that we’re seeing more and more where they predicated risk on size. So Belviq, was approved, but only for people with a BMI greater than or equal to 30. or patients who had BMI greater than or equal to 27, but also had what they are calling a, quote, weight related condition. And it’s probably a subject for another day. But the diet industry has spent so much money creating studies that link being higher weight to health conditions, in really dubious ways. And then it uses this mountain of evidence in these FDA risk benefit approval analysis to say see how terrible being higher weight is, that’s why it’s worth the risk. It’s worth killing or harming fat people to take these drugs to lose very little weight. So like that is a big part of it. But yeah, so they kind of hopped on this train that we’ll talk about more, I’m sure of predicating risk based on size, which again says that people have the highest weights, their lives are the least valuable in the most riskable, which is just pure weight stigma. There’s no other way to justify that. And this drug had serious side effects it decreased white and red blood cell counts, it slowed heartbeat, it slowed thinking heart valve issues, increased risk of cancer. And it was federally controlled, because of the possibility that it could be addictive. Oh, my God, it was really serious. Their study again, in their research, about half their subjects dropped out with no follow up. People who stayed lost like five to 10% of their initial weight within a year at two years, they had all gained back about 25% of their weight. Now, what we see consistently is people lose weight in about the first year. And then in years, two through five, they eventually gained back most or all of their weight, many gaining back more than they lost. And of course, nothing wrong with being fat or becoming fat but something seriously wrong with a healthcare intervention that has the opposite of the intended effect the majority of the time, but this is what we saw. And so what they did, and this is a trick you see so much in this type of research at the variable of weight gain was going straight up. At year two, they stopped counting and sort of pretended like it must have leveled off the minute they stop watching it, which you will fail freshmen research methods class if you do this 100%
Fi Willer 43:22
They do it all the time or they’ll cease the trial at six months where weight loss is maximal and just assume it’s going to be you know, continue on in forever. At the lower weight, it is so maddening so maddening
Louise Adams 43:37
Fi what is Lorcarserine or Belviq you’ve got it, you’ve got a special name for it.
Fi Willer 43:42
I have called this one brain zap because its effect is on neurotransmitters. And in general, we don’t really want to mess around with neurotransmitters if we don’t really know the long term outcome of that. Plus, if you have to take medications that affect your neurotransmitters to start with. So you may be on some antidepressant medication, lots of types of medication to help reduce the symptoms of conditions like bipolar disorder and ADHD. There’s a whole heap of things that already mess around with by brain chemistry, it is a very bad idea to put an extra type of neurotransmitter effecting drug in there. And so yeah, it’s you know, hugely bad idea. It’s got hallucinogenic properties. People developing psychosis Oh my God. Oh, this is not this. This is not the price that we should have to pay
Louise Adams 44:39
I think I’d prefer to shit myself. Yeah, I feel like I do
Fi Willer 44:43
feel like I’d be able to deal with that a bit better than completely losing my grip on reality because of the weight loss drug. Yeah.
Louise Adams 44:50
Goodness. So we this is the one that never got approved in Australia or the UK or Canada, but it was approved. In 2012, and then withdrawn from the market in 2020, in the United States after research again after it went to market on the human guinea pigs that showed increased cancer risk, so pancreatic, colorectal and lung cancer, and that’s from a five year cardiovascular risk study, they weren’t even looking for cancer, they were only looking at hearts, given the history of the weight loss industry, drug market, but these are serious cancers. This is really scary stuff. But it was on the market for eight years before anyone did anything.
Ragen Chastain 45:37
And it should be noted that it was a voluntary recall. They the FDA wasn’t like take it off the market right now. They offered Belviq manufacturer the chance to save face and voluntarily recall the
Louise Adams 45:48
drug. I think they do that a bit, don’t they? This is voluntary recall without any admission that any we’ve maybe killed people, we’ll just take it off just because, you know, we feel like it. Oh my goodness. So in October 2010, the FDA decided that it wasn’t going to approve a drug called Qysmia, which is phentermine Topiramate, and they expressed all of these concerns about this weight loss drug, potentially causing birth defects. And then it got approved in 2012. After the aforementioned lobbying efforts on the part of Big Pharma, you’ve got a special name for this one, too. Fi.
Fi Willer 46:29
This one I like to call zombie speed.
Louise Adams 46:33
What is what is zombie speed?
Fi Willer 46:37
So because it’s a it’s a double header drug, so we’ve got the phentermine part, which in Australia is a weight loss drug in its own right called Duramine, sometimes called ion immune suppressor, adipex and faston elsewhere, and that is a central nervous system stimulant. So it’s an amphetamine again, it’s speed, and in that itself, affects neurotransmitters as well makes you really jittery and that’s why it’s got this reputation for being energy burning. And then the other part of it is the Topiramate now topiramate is another type of drug that news was used originally to treat seizures, seizures and migraines. And they noticed that people that use the drug did lose some weight when they started using the drug for those other purposes, but a small amount, so three and a half kilos, about seven pounds in any other universe, that would be like, but of course, because we’re weight loss obsessed, drug manufacturers thought, holy crap, we’re sitting on a goldmine here, we could, you know, we can do something with this weight loss effect. So the side effects, they think what’s causing the weight loss as in people really just don’t feel like eating because instead they’ve got dry mouth, constipation, altered taste sensations, everything tastes like crap, or weird, insomnia, dizziness, psychomotor, slowing decreased concentration and attention, memory impairment and language difficulties Good Lord Wonderful. So it’s also strongly linked to birth defects. So that’s fantastic. But the combination of that speed effect and the appetite, blunting effect of everything tasting like crap is what they packaged together as a as a weight loss medication.
Louise Adams 48:17
It’s just not for the faint hearted this conversations, it’s really awful. So side effects, rare pulmonary hypertension, tachycardia, palpitations, high blood pressure, stroke, heart attacks, cardiac arrest,
Fi Willer 48:32
these are all essentially the effects of the amphetamine components, just like fen phen.
Louise Adams 48:37
So they when they did get approval after the rejection, it came with a warning for patients and also an instruction to do a risk evaluation and mitigation strategy, or REMS, which means they have to do like more research to follow up on these kinds of risks. So this is, you know, more human guinea pig experiments that are going to come out but it’s still available. Can you believe it?
Ragen Chastain 49:04
I think its is just a testament to the first of all, I think there’s this sentiment that’s based on waiting with it, that fat people probably do need to suffer, like, obviously, fat people. So there’s this first of belief that what we have to do is keep these people from eating this is not scientifically based, right? The assumption that what we should do is figure out how to suppress fat people’s appetites, how to get them to stop eating, that’s not scientifically based, that’s a prescription for mal nourishing higher weight people. But then there’s also this underlying thing of like, you know, maybe they do need obviously food does need to taste bad to them, because we all know that fat people just eat too much and all the wrong quote unquote, wrong things. And like all of these stereotypes become entrenched in the FDA approval process of medications.
Fi Willer 49:45
And unfortunately, even some dietitians still believe that if somebody has a larger body, they must be continually overshooting their energy requirements in their eating practices. But that is actually not happening if somebody’s weight stable but just exist. In a larger body, not but and existing in the larger body, they’re eating what their body needs. And that’s the fact that how weight balance happens, and into balance. But yeah, this this belief that you’re wearing your lifestyle on your body is so pervasive. And that is the machine that drives stigma because of the misperception that it’s simply a matter of choice. And you know, volition, whether you exist in the small body or larger body, but the whole, you know, those that they’re the pins that are holding this machine together without those, the stigma should theoretically disappear. Of course, Old habits die hard.
Louise Adams 50:37
Yeah. So although it’s not available, technically, in Australia, GPS in Australia are prescribing the two different medications which are approved, off label,
Fi Willer 50:47
take them together, and basically what you get is that,
Louise Adams 50:52
yeah, yeah, so really, really dodgy. And I also found out that in 2022, FDA approval was gained to sell this drug in the United States to adolescents aged 12 to 17. So that’s a nice expanding market for them.
Fi Willer 51:09
I just I think, I mean, there’s the symptoms, the side effects are so bad with this kind of drug that they have to be playing on the well. Let’s try this drug first. And let’s try this struggle. It’s, it’s not that there are a huge number of people who are taking this and only this, it’s that there are millions of people who try this, and then it goes by the wayside, because something else has picked up or we find Health at Every Size, or whatever. But it’s that there’s this never ending new market for people seeking solutions. I guess it’s got to be that usage, because these side effects are dreadful. Yeah, yeah,
Louise Adams 51:47
the impact in actual weight changes, of course, pretty pathetic.
Fi Willer 51:52
It’s not even a blip in longitudinal study, like, yeah, less than interesting what it does to weight. Yeah,
Ragen Chastain 51:58
yeah. And with Qysmia, if you stop taking it, suddenly, you can have withdrawal symptoms, including seizures. Yeah, in the States, because our we don’t have single payer. So it’s entirely possible that someone would find themselves unable to pay for their drug and unable to access it. And there may be what they call compassion programs. So I would point out that if you had compassion, you wouldn’t need such program. But they are where you can access the drug, but they would not be able to do that immediately. So it’s possible that this could be induced in in folks in the States because they simply would lose access to the drug.
Fi Willer 52:32
Yeah. Plus, it takes a lot of personal organization to be able to find all of these different options to continue your medication supply. I mean, I read about it, and it just horrifies me by really, yeah, the Australian system is is different. Not perfect. But yeah, there seems to be less loopholes and potholes.
Louise Adams 52:53
Yeah, yeah, neither. Yeah. But it’s just this is literally Yeah, I don’t know. It’s it’s hard to I mean, you can see why this one was rejected initially, before all of that lovely pharma money went into approving it. And then the last one that we’re going to talk about is naltrexone and buproprione, also known as Contrave, and I think you have a special name for this again, fee.
Fi Willer 53:16
This one I’ve called Narcotics R Us.
Louise Adams 53:18
So Contrave was again rejected in 2011, because they wanted long term clinical trials, evaluating particularly cardiovascular risks. But then, of course, after a bit of strong arming, it got approved in September 2014, with a blackbox warning, which is the highest level of warning the FDA gives out. And it states that the drug can, in rare circumstance, increase suicidal thoughts and behaviors in adolescents and young adults, and can cause mania and depression to return in people who have previously suffered from those conditions and also can cause seizures and a strange condition where eye pressure rises rapidly. So what is this magical weight loss drug? Fi?
Fi Willer 54:07
Well, this is another this is another drug that came from ideas about larger bodied people that aren’t true. So one of the parts of this drug the let me just make sure I’ve got the right one, naltrexone part decrease. That is the one that’s used to help people reduce their drinking habits. Yeah, cravings It’s it’s not hugely effective. But for some people, it’s it is quite effective for them. But it’s not this. It’s not a sort of blanket excellent drug for that either. But the way that it works is that it blocks people’s potential to experience pleasure from food substances. So it’s sitting there they said that the way it made it into this combo for weight loss is the assumption that larger bodied people are sitting around just pleasing their tastebuds or having pleasure how awful constant dopamine hit from food. And so they thought, Oh, well, this, this alcohol suppression drug that might work because clearly same problems just pleasure seeking the whole time we think, actually us people that work in food and eating practices for people across the BMI spend know very well that actually pleasurable eating is something that is engaged in by all different sizes, shapes of humans. And large bodied people are not in any way different from small bodied people in terms of the amount of pleasure that they get from food, and they’re certainly not larger body because of the pleasure seeking part of it. So it’s no surprise to me that it’s not terribly effective as a drug. But that, you know, this is how stigma ends up, you know, in the research lab in the heads of scientists saying, oh, what will be a good solution for it, or because of all these things that they must be doing. And the other bits that is in this narcotics are US drug is bruproprione, and let me see what we are. And it’s an anti depressant. So again, the I’d forgotten this part about it, it blocks nicotine from getting into the receptor, where it can make you feel good. So it’s just that it’s blocking another type of feel good receptor. This is an anti smoking drug buproprione. So
Louise Adams 56:20
yeah, lovely. Okay, so at first not feel any pleasure, and maybe get 5% weight loss, I’m assuming, which is the same as all of the other
Fi Willer 56:29
trials. And again, it’s only going to be effective in people for whom that is a driver of their major driver of their eating behavior. And their metabolic circumstances are such that their bodies at that time will, you know, allow the metabolism of some of their body tissue stores, that’s also not the case for everyone as well, because there’s a huge variability in people’s bodies, responses to an energy deficit, but it’s for those people who are whose bodies do lose weight with this drug, they’re the ones who are most likely to stay in these trials. So the effectiveness is hugely overstated, because it’s not representative of the typical experience. The people who enter a weight loss trial wanting to lose weight, and who do not have that experience, tend to not actually want to face up to the researchers because they feel ashamed that the drug has not had the effect that they know, the researchers hoped that it would. So it’s a very human response to expectations that are unattainable. But we’ve got this, it’s contaminated the research findings,
Ragen Chastain 57:32
also the fact that researchers have been allowed to simply ignore dropout populations, like if I was told that if two thirds of your sample nopes out, halfway through, you’re responsible for caring about that, or at least addressing it in the discussion, not semantically erasing them to make your intervention seem like it has higher efficacy than it does.
Fi Willer 57:51
And intention to treat exists, right. That’s a type of analysis. That means that you count the people who’ve dropped out, and you assume you don’t assume anything about their outcome, you assume that there’s been no change, which is not perfect, because sometimes there is change, but it is not in the direction that you hope, right? That’s the reason. So it’s not perfect, but it’s certainly better than Oh, well, you know, we started with 100. Now we’ve got 20, Let’s just analyze those 20. Because that is literally the way that many weight loss studies, analysis operates. And that’s so deeply, like misleading in terms of figuring out what the effect of the thing that you’ve done people is,
Ragen Chastain 58:28
or stop the study when everybody’s at their lowest weight and then use intention to treat and say, Everybody worked and nobody gained weight back. So yeah, everybody. It’s the way that people manipulate things that were meant to create better analyses. And within its I know, it’s not only unique to weight science, but it was when I first started doing literature reviews and started digging in, I was utterly shocked. Yeah, again, things that would have gotten me failed as a Freshman Research Methods students that were being peer reviewed and cited by major national, you know, the American Diabetes Association and these organizations. So yeah, it’s, it’s hard to believe,
Fi Willer 59:05
I think, the wild west and because of the paywalls to a lot of these articles as well, you end up with journalists who are unable to access the full version of the paper. So they have to go and that literally 250 to 300 words supplied by the authors about you know, the summary of the paper has a very, very sanitized outcome and they it is like an ad for them. So, especially since what they feel like will cause people to click through and you know, access the paper purchase the paper. So again, it’s not representative and you cannot I always tell my students as well, you need to actually read the Methods section and the results section you cannot rely on the conclusion section that is creative writing the conclusion section is creative writing. The other bits are more scientific, but boring science bits. That’s what you have to look at. Literally, the last three or four sentences in a conclusion are basically the author’s hot takes on what should happen next. Right? So you cannot rely on that you need to interpret their paper through fresh eyes. Don’t Don’t just take the author’s word for it. No,
Louise Adams 1:00:13
I want to give a special shout out to Contrave for having perhaps the most fat phobic advertising campaign that I’ve ever seen on the planet, like ever. We’ll put a little screenshot up in the show notes, but I was showing you guys earlier, the picture of about Contrave and its impact on cravings. The best way to depict that, visually is to show a larger bodied, well not even a particularly larger bodied lady who’s running and she’s being chased by a tornado entirely made up of fat bellies. And, okay, yes, yes. That she’s out running her cravings, thanks to Contrave disgusting shame on you. Absolutely horrendous. Essentially, fat shaming campaign
Fi Willer 1:00:59
so condescending, I cannot even it’s awful.
Louise Adams 1:01:03
But it kind of gets a little worse with Contrave having, having kind of escaped their initial refusal with the FDA and then getting it thanks to kind of hustling Congress, the FDA said, Look, you can do you can release this drug. But you do need to do follow up cardiovascular trials because we need to do our due diligence, quote unquote. And that hasn’t happened because the drug company has had a hissy fit with its own parent company. So orexigen was the original company that had contrave and then it got sniffed out by tequila and bought by Takeda, who thought they could make bank off Contrave. And then during the first cardiovascular outcome trial, orexigen, accidentally shared some confidential information from their trial, getting them in quite a lot of legal hot water. And so Takeda dumped them, and they had no money. So this cardiovascular child still hasn’t been published. So thanks to this kind of absolute bin fire that happened after the drugs on the market. We don’t even know what’s happening to people that we’re taking in terms of their cardiovascular risk. And given the history of weight loss drugs, we really need to stick to this and find out what’s happening. Absolutely. Next level, right.
Ragen Chastain 1:02:22
There’s an interesting piece about like the level of research required for things. So we approve that like, there’s a ton a century of research saying most people lose weight and gain it back. There’s a ton of history of serious side effects and drugs having to be pulled. But we’re still giving drugs the benefit of the doubt based on as you know, a study that lasts less than two years. But when we say well, what about the side effects? Or like, what about the side effects of weight cycling? Oh, well, there’s not sufficient data to conclude that those side effects are because of weights? I would really because I’m looking at studies for you know, decades. Oh, well, that’s not sufficient data. So there’s a real good hypocrisy and unfairness about what is weighted for approval, versus what is weighted for not approving pulling a drug requiring more evidence before we say this is a let’s go.
Louise Adams 1:03:13
Yeah, I mean, it’s a diabolical history, weight loss drugs and off the back of all of these disasters. So we’ve literally looked at six drugs and four of them have been taken off the market. It’s it’s absolutely diabolical, unmitigated disasters, the history of weight loss drugs. And And to
Fi Willer 1:03:33
summarize, they haven’t taken been taken off the market for ineffectiveness. That would be one thing. they’ve been taken off the market because they keep killing people.
Louise Adams 1:03:41
Yes, good point. Well, we’re gonna leave it there this week, everybody, because there is a part two coming to this when we turn from the past into the present. And we’re going to dive in next episode into the world of Novo Nordisk, and its push to get diabetes drugs on the market as their weight loss, cash cows. I hope today has been really enjoyable for you. Thank you to my guests Dr. Fi Willer and Ragen Chastain aren’t they just absolute legends, I’m really encourage you to go and find out more about both of these people. If you aren’t already following them. You can Fi Willer at fionawiller.com and you can find Regan at danceswithfat.org Follow them love them. They’re going to change your life. Thank you everyone for listening today. I hope it has been an eye opener because I know it was certainly when I did months and months of research for it. Thanks everyone for being patient with me as this year has kind of slowly drifted past with no episodes. I really can’t wait for the next one. I hope you’re still with me. In the meantime, trust your body. Think critically, push back against diet culture untrap From the crap
Transcribed by https://otter.ai