5HT #119: how to survive a health gold rush, celebrating my biological age, and 3 more

In our optimization culture, there’s opportunity everywhere—from peptides to protein. Buuut not every opportunity is pursued ethically. Or legally. 

So, let’s talk about how to survive a gold rush… without going to prison.

Two stories from this summer:

🎥 In July, Ruthia He—founder and former CEO of telehealth startup Done—was sentenced to six years and fined $1M for a $90M scheme that pushed over 37M Adderall pills through a subscription-for-prescriptions model. Done spent $40M+ on social ads convincing people they had ADHD, paid clinicians to sign scripts every 30 seconds, and auto-refilled patients (even if they were on involuntary psychiatric holds or dead??). The goal was a $1B valuation. (DOJ asked for 20 years, so six feels light.)

🎥 In June, Chainalysis reported that crypto payments to gray-market peptide vendors hit $32M in Q1—up 159% in one quarter, on a $100M+ annual run rate. Some of those suppliers are Chinese chemical manufacturers who pivoted off fentanyl precursors to sell peptides to American biohackers. 😳

Different drugs, but the same idea: Demand outruns supply and the gap gets filled by whoever moves fastest. Sometimes that's a venture-backed startup. Sometimes it's a two-person company running thousands of ads under AI-generated fake doctors and deepfaked before-and-afters.

Here's my actual take: riding a gold rush is a legitimate strategy, but you have to ride it right (and legally). Disclaimer: I’m an advisor to a company called The Protocole that I believe is doing this right. They and other great operators are doing the below already.

1. Know what clock you're on. The FDA advisory panel voted to ease restrictions on six peptides last month, but it’s estimated to be 8–12 months before compounding pharmacies can offer them. In the meantime, co’s are either selling compounded "components" of FDA-approved drugs (like semorelin, GLP-1s), currently legal peptides like SS-31/branded GLP-1s, or they're betting the FDA won't act on things like BPC-157 until the new rules go into place (a dangerous, but calculated game to play). Prepping now is the smart move, though—getting your processes ready, your experience dialed in, your marketing engine humming, etc.

2. Treat the gray zone as a customer acquisition channel, not a P&L. The compounded semaglutide window opened, printed money, and slammed shut in about 24 months. Most of the co’s who built fixed costs against that revenue got crushed (and/or cracked down on). But time it right and you can use the window to buy customers cheaply, then move them onto something that survives the window closing. If your unit economics only work in the gray area, you’re on short clock. Point is: Diversify before Costco shows up (because they’re showing up, see below).

3. Be the tortoise, not the hare. Buyers want stuff they can trust, not pill mills and “for experimental use only” labeling. So, show off your experts and clinicians. Get as much third-party testing as possible. Name your pharmacy. The more you can signal you’re trying to do it right, the more buyers (and all interested parties) will believe you. As tempting as it may be to push product and grow, here you actually do want to compromise on speed to last long term. 🧪

4. Make friends with the people who can end you. Ro is the case study here. It kept both Lilly and Novo partnerships alive by playing inside the lines, and now offers branded Zepbound and Wegovy through LillyDirect and NovoCare. WeightWatchers publicly walked away from compounded semaglutide and kept its seat. Pharma, regulators, clinicians, pharmacies… Every one of them can turn your business off. Journalists, competitors, and customer complaints can do real damage. So play nice!

Bottom line: Do reach for the gold. But prep well, play nice, and diversify fast. And don’t do anything illegal. Otherwise:

I celebrated one more year of not turning 40 on Tuesday. (It’s my last one, okay?) 

Unlesssss I use my biological age, which, according to Function Health, means I’ve got another decade 😌.Thanks, Function, for keeping me young, and kudos on the excellent email marketing 👌.

Experts say major retailers and pharmacy chains are expected to win as employers drop GLP-1 coverage and push patients toward DTC options. As I mentioned above, it’s always felt inevitable that’s the case when innovations get wildly popular. 

Eventually (and maybe ironically?), the biggest gains don’t go to the startups or independents, but the incumbents. I mean those with the existing infrastructure—the customer relationships, the distribution, the marketing. They’re often better positioned to see the upside. Yes, the rich get richer. 🙄

Worth saying this is essentially what’s playing out in AI. Apart from the frontier models (and maybe some niche, verticalized solutions like OpenEvidence), established businesses like Amazon, Meta, or Salesforce are more likely to win.

Just know that, going in, there’s essentially a tipping point where what you’re building becomes TOO successful, and suddenly every bodega is selling Dubai chocolate. Know what I mean?

Health media continues to shrink, so I’ve been hiring the talented people it lets go.

Here’s why: These newsrooms have spent decades training the best health content people in the world. Editors who can pressure-test a study. Designers who understand how to visualize sensitive topics. Writers who interview clinicians instead of paraphrasing them. 

The skills big publishers can’t monetize anymore are exactly what health brands need right now, which is why we've been deliberately recruiting them at Healthyish Content.

Because journalists do what AI can’t. 

👉 Journalists verify. Two medical experts review every article we publish.
👉 Journalists source. They don't summarize search results; they call experts.
👉 Journalists have taste. They know the difference between the best answer on the internet and the tenth-best.
👉 Journalists think in narratives. They can tell a story that engages, sticks, and drives action.

The takeaway: Health media's loss is your hiring pipeline. If you’re looking for top talent, I post a roundup of new gigs every Monday on LinkedIn. Share your open role with me, and I’ll share it with my community of health content people. (Orrr you could hire Healthyish Content, that's cool too 😉.)

I never thought I’d be someone whose parents died young. But this past weekend, my Mom passed away after a 10+ year fight with Alzheimer’s.

5HTers have been on this journey with me. Preventing Alzheimer’s became a major driver of my health journey over the last few years—and this newsletter became a form of accountability as I continue doing everything I can to prevent this terrible disease. 

Because Alzheimer’s really is terrible. You watch someone you love become a shell of themselves while still looking like your mother, and it never gets easier to make sense of.

That’s why, in many ways, my Mom dying this past weekend was actually a huge relief.

That may not make sense to anyone who hasn’t navigated Alzheimer’s or experienced this anticipatory grief. But the reality is, I’ve been mourning my Mom for 15 years.

She was diagnosed early at 65. By then, we were already beginning to lose her. Within three years, she was mostly gone. There were fleeting moments when she recognized me, but eventually those disappeared too.

In the last decade, Alzheimer’s stole so much from us.

My Mom never got to know my two beautiful kiddos (with a third on the way).
She never got to build a relationship with my amazing wife, Sara.
She never got to see me sell my first business, Greatist.
And she never got to support and parent me through the many hard moments, too—another startup that failed, heart surgery, and more.

It’s awful and heavy and a million other things, none of them good. So many families affected by Alzheimer’s quietly endure the same tragedy: the not-yet-dead years. The resources consumed while caring for someone they love. The hope, year after year, for one more brief moment of recognition that never comes.

So, as much as I’ve been crying, I’m also glad it’s over.

And now that it is, I don’t want to remember my Mom for the final decade of her life. I want to remember who she was before—to celebrate her amazing life and tremendous history.

So, let me tell you about my pretty incredible Mom:

My Mom was born in Russia. She experienced tragedy very young. Her mother died when she was less than 10 years old. She was raised by a single dad, my grandfather, who was one of the great veterans of World War II and someone I feel lucky to have spent time with growing up. My Mom was diagnosed with a congenital heart defect and had one of the first open-heart surgeries in communist Russia's history, becoming a minor celebrity because of it.

That wasn’t my Mom’s only brush with fandom, though.

After becoming a dermatologist, she dated someone who was basically the Seinfeld (or like David Letterman) of Russia named Mikhail Zhvanetsky. When that didn’t work out, she emigrated to the United States alone. She was in her 30s when she landed in New York City, learning English and earning her MD at the same time (including a residency at Stanford, nbd). She met my Dad, fell in love, and later had my brother and me.

My Mom was in some ways a classic Jewish Russian mother, one who’d fight for everything. Though she didn’t come from opportunity, she created them for herself and made sure my brother and I would have them too. I owe much of my entrepreneurial spirit and success to her.  

When my brother and I went off to college, she devoted herself to art. By then, we were living in Miami (basically bereft of culture 😬), where she helped bring the city’s first contemporary art museum to life. Eventually, she joined the board of directors at Tate and became a key champion of bringing Soviet state art into its collection.

She was a true force—and the center of attention at the party. I used to joke that her Russian accent got worse because she realized she could get away with more. I remember her once getting out of a speeding ticket using her Russian accent (even though she had lived in the U.S. for 20+ years)

She was truly a special person—a fiery, smart woman who fiercely fought for her children and was a joy to be around.

It’s this memory of her I want to hold onto.

Alzheimer’s may have stolen her memory, but Alzheimer’s won’t steal how I remember her.

Most clicked last week: The crone era is here.

👋 Who are you again? I’m Derek Flanzraich, and I’m in the business of healthyish. I founded two venture-backed startups–Greatist (👍) and Ness (👎)—and helped dozens of brands you know grow including Ro, GoodRx, Midi, BetterHelp, and LMNT. I now run Healthyish Content, plus a few other healthyish things (like Fixie Dust, launching this fall).

Every Thursday, I share what’s hot, what’s not, and what’s next in consumer health. (Disclosure: I invest in and advise companies in this space—when I cover one, I'll say so.) I sometimes add affiliate links, but they influence my picks zero.

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