Apr 21, 2026 · 1h 38m · invest-like-the-best
GLP-1s, Peptides, and The Trillion-Dollar Health Revolution · Invest Like The Best
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In this episode of "Invest Like The Best," host Patrick O'Shaughnessy interviews investor Alex Carnell about the ongoing transformation in biotechnology, focusing on GLP-1 medicines, preventive healthcare frameworks, and AI-accelerated drug discovery. Carnell details how shifting healthcare from reactive treatment to proactive longevity and friction-free therapeutics will unlock a multi-trillion-dollar revolution in public health.
How this conversation actually went
Every chapter scored 0–10 on four independent dynamics. Hover any point for the reasoning behind the score. Patrick holds 16.7% of the talking time here. How this is scored →
Patrick as informed peer 4.2 Guest teaching 7.5 Guest disagreement 0.3 Patrick pushing back 0.5
speaking balance: gold is Patrick, purple is the guest (3 minute bins)
Sharpest disagreement ▶ 29:07 Pushing back against diet-only equivalence
Alex directly counters Patrick's question about whether strict dietary discipline can replace GLP-1s, citing evidence that cardio protection and neurochemical addiction modulation operate independently of caloric restriction.
Hardest push from Patrick ▶ 40:49 Patrick presses on biological trade-offs and zero LDLPatrick challenges Alex's assertion that PCSK9 inhibitors represent a free lunch, questioning whether completely driving LDL down disrupts natural biological functions.
Biggest teaching moment ▶ 36:50 Genetic origin of PCSK9 inhibitorsAlex educates Patrick on how observing natural loss-of-function human genetic mutations led directly to synthetic monoclonal antibodies and RNA interference drugs that reduce cardiovascular risk by up to 88%.
Patrick holds their own ▶ 58:28 Patrick probes whole-body preventative imagingPatrick brings up specific innovative imaging companies like Prenuvo and Neko to evaluate their diagnostic role within preventative health stacks.
the scores for every segment, with the reasoning behind each
| Chapter | Topic | Patrick as informed peer | Guest teaching | Guest disagreement | Patrick pushing back | Why |
|---|---|---|---|---|---|---|
| State of Medicine and the GLP-1 Public Health Revolution | 3 | 7 | 0 | 0 | Patrick sets the stage by asking Alex for a broad industry dispatch on the state of medicine. Alex delivers an extensive overview of GLP-1 adoption, arguing that proven targets already exist for most fatal diseases and framing GLP-1s as commercial proof of an impending trillion-dollar public health revolution. | |
| The Health Stack Framework and Five Defensive Layers | 4 | 8 | 0 | 0 | Patrick introduces the co-developed health stack framework, prompting Alex to unpack the offensive and defensive layers. Alex systematically walks through lipid optimization, cardiometabolic health, neurocognitive health, inflammation, and blood pressure with detailed clinical data. | |
| Mid-Roll Sponsor Advertisements for Ramp, WorkOS, and Rogo | 4 | 7 | 1 | 0 | Following sponsor reads, Patrick asks what specific catalysts are driving the 2025-2026 GLP-1 acceleration. Alex explains that consumers prioritize tolerability over raw efficacy and highlights the massive inflection caused by digital direct-to-consumer distribution, compounding price elasticity, and oral formulations. | |
| Biological Mechanisms and Market Segmentation of GLP-1 Therapeutics | 4 | 8 | 0 | 0 | Patrick asks Alex to break down the biological progression from single to dual and triple receptor agonists. Alex details endogenous GLP-1 half-life, receptor pharmacology across the gut and brain, and frames the market across BMI segments. | |
| Non-Caloric Health Benefits of GLP-1s Beyond Weight Loss | 5 | 8 | 1 | 2 | Patrick pushes with a direct hypothesis, asking whether perfect dietary adherence would achieve identical outcomes to GLP-1 therapy. Alex refines the premise, noting that while diet addresses weight, GLP-1s confer independent cardiovascular benefits, glycemic regulation, and central satiety signaling against addictive behaviors. | |
| Overcoming Systemic Friction: Complexity, Cost, and Compliance | 4 | 7 | 0 | 0 | Patrick prompts Alex to address why existing lifesaving medicines fail to reach widespread adoption. Alex breaks down systemic barriers into complexity, cost mismatch for chronic therapies, and compliance friction. | |
| PCSK9 Inhibitors and Cardiovascular Prevention | 5 | 8 | 1 | 3 | Patrick brings up PCSK9 inhibitors and challenges whether an actual biological 'free lunch' exists, probing what scientific skeptics would argue regarding near-zero LDL levels. Alex clarifies the difference between GLP-1 side effects and the genetic validation of PCSK9 loss-of-function variants. | |
| Breakthroughs in Neurodegenerative Diseases and Alzheimer's Prevention | 4 | 8 | 0 | 0 | Patrick frames neurodegenerative diseases as an historical wasteland and asks what has changed in Alzheimer's treatment. Alex outlines the shift from late-stage plaque reduction to early intervention and preventative clearance. | |
| Mid-Roll Sponsor Advertisements for Vanta and Ridgeline | 5 | 8 | 1 | 1 | Patrick explores cancer diagnostics and asks whether full-body imaging technologies like Prenuvo are worth the investment. Alex educates on sensitivity versus specificity and warns against actionable disruptions caused by high false-positive rates. | |
| The Scientific Method, Capital Allocation, and Drug Discovery | 4 | 8 | 0 | 0 | Patrick asks Alex to demystify the core discovery process from scientific intuition to commercial medicine. Alex articulates the step-by-step scientific method, preclinical animal models, toxicity margins, and regulatory hurdles. | |
| Artificial Intelligence, Automated Robotic Labs, and Scientific Superintelligence | 5 | 8 | 0 | 0 | Patrick asks how AI models compress drug discovery timelines and whether this inflection is inevitable. Alex explains agentic robotics, automated screening, in silico molecule generation, and proprietary wet-lab token generation as the real competitive moat. | |
| Grassroots Biohacking, Peptides, and Regulatory Modernization | 5 | 7 | 0 | 0 | Patrick asks about the surge in grassroots peptide biohacking and DIY citizen pharmacology. Alex contextualizes this subculture as patient agency meeting modern communication platforms, complemented by regulatory modernization efforts at the FDA. | |
| Alex Carnell's Career Journey: From MIT to Deerfield and Braidwell | 3 | 6 | 0 | 0 | Patrick asks Alex to share his personal career trajectory. Alex recounts lessons from his entrepreneurial parents, graduating MIT, working on the Merrill Lynch derivatives desk, his 15-year tenure at Deerfield, and founding Braidwell after observing that patients were discontinuing chronic lifesaving therapies. |
Statements from this episode (29)
Carnell: GLP-1 class will easily surpass $100B in annual revenue
“And I think it's easy now to conclude that this is a class of medicines will easily be in excess of a hundred billion dollars a year in revenue.”
Carnell: Scientists have already found medicines for most fatal diseases
“Is that incredible scientists have already cracked the code on most of the medicines we need to protect us from most of the diseases that will claim most of our lives.”
Carnell: Existing medicines can reduce middle-aged cardiovascular risk below 10%
“Most middle-aged men and women walking around have somewhere between a 30 and a 50% probability of having a heart attack and a stroke sometime between the time that they turn 40 and the time that they turn 80. And to me, that's tragic because we have the medic…”
Carnell: Eli Lilly data shows GLP-1s cut diabetes progression by 94%
“We've got amazing GLP-ONE medicines that I started with that from clear data out of Eli Lilly show a 94% reduction in your risk of moving from being pre-diabetic to diabetic.”
Carnell: Early proactive medicine will add a decade to expected lifespan
“Each of them has medicines available that if we could get on them early and be proactive about where we're going with our health, they will undoubtedly add an extra decade of life to our expected lifespan and have the potential to take curves that have been de…”
Carnell: GLP-1 Patients Value Tolerability and Maintenance Over Maximum Weight Loss
“People are not solving for this massive bazooka. People are solving for something that helps them to lose some weight, stabilize and be there. And I think that's really interesting because what that means to me is that what people really want is something that…”
Carnell: 15% to 20% of GLP-1 Demand Flows Through Telehealth and Compounding
“Somewhere between 15 to 20% of the market that you couldn't capture through scripts was actually flowing through groups like hims and hers and other sources where people knew they wanted the benefits and wanted to be proactive about their health.”
Carnell: Oral Wegovy Lifted Weekly New GLP-1 Prescriptions to 300,000
“Prior to the launch of the oral Wagovi, just a few months ago, the GLP one market was moving at about a 200,000, you know, recorded new scripts Per, per per week. 200,000 new people getting on these medicines per week. The most recent data that I looked at thi…”
Carnell: No molecule is more important for longevity than GLP-1
“I fundamentally believe there's no molecule that's more important than GLP-one across that entire axis.”
Carnell: Semaglutide and tirzepatide are clinically interchangeable despite distinct IP
“Our team's fundamental perspective is that they all achieve the same goals. They were just novel IP strategies to achieve those same goals. And I would say that they're all pretty much interchangeable.”
Carnell: Low-dose GLP-1s will likely be appropriate for almost everyone
“I would argue in the future, we could talk about why GLP-ONE's might be appropriate for just about everyone. That's because the reality of it is, as you go from your adolescence to your fifties and sixties, On average, people are going to pick up about five BM…”
Carnell: Upcoming data will show GLP-1s protect against addictive behaviors
“In terms of the addiction data that'll start coming out over the next year or so, you would lose that benefit. Like you would lose the, essentially the free gift of protecting yourself from being addicted to drugs, alcohol, or gambling. And that comes from the…”
Carnell: Novo Nordisk data shows GLP-1s cut cardiovascular risk over 20%
“We've got compelling data right now, ah, out of Novo Nordisk over the last year that basically shows that by taking GLP-I medicines, there is a, you know, north of 20% reduction in our risk of having a heart attack or a stroke. And what I thought was pretty pr…”
Carnell: Direct-to-consumer channels drive most GLP-1 adoption today
“What we're seeing with GLP One Medicines and what we're seeing that the direct-to-consumer side of that is driving most of the adoption today”
Carnell: Chronic preventative drugs are improperly priced like acute treatments
“Most medicines that we need to be on for the rest of our lives that are going to be providing the chronic care, the different layers of that defensive health stack that will protect us from these diseases, those medicines today are priced as similarly to acute…”
Carnell: Monthly and quarterly GLP-1 formulations are a massive unlock
“We went from twice a day to once a week, and now we've got versions that are once a month, maybe once a quarter. That's a huge unlock in my opinion.”
Alex Carnell: PCSK9 medicines lower LDL cholesterol by 50%
“PCSK nine medicines are amazing because what they do is they today can lower our bad cholesterol, that LDL cholesterol by 50%.”
Alex Carnell: PCSK9 drugs reduce cardiovascular event risk by 20% to 25%
“And so in patients that have previously had a heart attack or stroke, we can reduce that risk by over 20% in the future. And for people that are at high risk of having a heart attack or a stroke, the medicines that are approved and on the market today can lowe…”
Alex Carnell: Genetic PCSK9 deficiency reduces cardiovascular disease risk by 88%
“With longitudinal studies over 15 years, the fact that they were genetically deficient in the production of the PCSK-IX protein led to them having an 88% reduction in the risk of ever developing cardiovascular disease.”
Alex Carnell: PCSK9 drugs should eventually surpass GLP-1s in revenue and patients
“And I would argue because it is more asymmetric, it is more in the degree of that free lunch, I would argue that if you just project down the road longer term, this medicine should be far bigger in terms of the number of people that, that are on it and the rev…”
Carnell: Biogen and Lilly Alzheimer's Drugs Slow Cognitive Decline by 30%
“And so, today, we've got some amazing medicines that are both Biogen and Eli Lilly, that if you are late in the disease progression of Alzheimer's, You can start to slow the decline. We can slow that decline by about 30%, and so intuitively that just gives us …”
Carnell: PCSK9 Inhibitors Have More Favorable Risk-Reward Than Statins
“If you start taking a PCSK nine inhibitor earlier in your life, Which, by the way, I think the risk reward is actually even more favorable than statins in terms of human health, but we know that you won't progress to cardiovascular disease.”
Carnell: High-quality multi-cancer early detection tests will emerge within five years
“And I think over the next three to five years, particularly with how AI and the evolution of these tests are really converging to help them to move faster and faster and to be better and better I think we're gonna wake up within the next five years with really…”
Carnell: I do not personally use whole-body imaging scans
“So for me personally, I'm not yet pursuing those. I, I'm very much focused on areas where if we're going to go and do a test, it's going to have a high probability of capturing what I'm testing for and a low probability have given me a false reading.”
Carnell: Documented scientific failures would be more informative than published successes
“I think the unfortunate part of the literature is that what's often missing is all the failures, which would be even more informative than successes.”
Carnell: AI will speed drug breakthrough timelines from 3-5 years to under 2
“The sheer ability to be more comprehensive and complete in our hypothesis set, and then the sheer ability to run Experimentation at a scale that's unprecedented, I think practically means we are going to be able to speed breakthroughs from timelines that would…”
Carnell: AI drug platforms compress model-to-molecule timelines to one month
“What we have today are companies that can go from what would historically been running these massive screens that are incredibly time consuming to doing all of that screening work in silico and can go from model to molecule and what would have taken a couple o…”
Carnell: Winning AI biotech firms must generate proprietary science tokens
“The AI companies that I believe are going to be most set up for success are the companies that have incredible AI talent have access to significant amounts of capital, and can combine both of them with a novel way by which they can generate science tokens that…”
Carnell: FDA brought in AI to review sponsor filings in record time
“Marty brought in an AI system to help them be able to comb through the thousands of pages of filings that sponsors behind medicines have to submit in record time versus the, you know, armies of people that would have to comb through that and the days and days …”