You’re in the exam room at your doctor’s office. Maybe it’s for an annual check-up. Maybe you’re there for a specific concern. Then it happens. Maybe the doctor prefaces it by asking permission to discuss your weight. Maybe they cut straight to the chase (“There’s a drug I think you’re a good candidate for” or “Have you considered taking a GLP-1 to help with your excess weight.”)
I honestly have no idea what they would say, exactly, just that they would either approach the topic indirectly or directly, and they might either try to reduce the amount of stigmatizing language they use, or they might not even care about that.
Either way, there it is. The topic’s been broached, the recommendation is out there. What do you do next?
Take a breath and ask some questions (if you want to)
You could say “No.” Literally “No,” if they asked a yes-or-no question, or “This isn’t something I’m interested in/I want to discuss” if they asked an open-ended question.
Maybe you’re not interested in pursuing weight loss in any form. Or, maybe you know enough about the medication that you know it’s not for you.
Again, you have body autonomy, you have the right to say no.
But what if you don’t want to shut down the conversation? Maybe you’re curious, or maybe you’ve already considered one of these medications? Here’s what I suggest.
Ask your doctor why they’re recommending this medication. If you are currently living in a fat* and healthy body, and they say something about how your current weight will affect your future health, that’s a red flag. They are a physician, not a psychic. That’s why you have preventive health care, to watch for any real health problems that are ACTUALLY emerging.
*I use fat as a neutral descriptor of body size, because the O-words medicalize body size regardless of a person’s actual health status.
Also, there abundant research that when people follow basic health-supportive habits — eating adequate fruits and vegetables, being physically active, avoiding tobacco and consuming alcohol in moderation (or not at all) — the association between weight and risk of dying prematurely starts to level out between the different BMI categories.
And if you’re not currently following all those health-supportive habits, well, that’s something tangible and actionable that you could work on. That might be a good conversation to have with your doctor.
It’s worth pointing out that people with normal blood sugar or blood pressure or cholesterol don’t start taking drugs for diabetes or hypertension or high cholesterol just because they’re at increased risk for one of those conditions.
Informed consent: understanding GLP-1 medications
You can ask your doctor what will happen if you decide to take the drug but later decide to go off it. If they say anything about the drug
- Lowering your body’s weight setpoint permanently, or
- “Jumpstarting” weight loss while you work on diet and lifestyle changes to maintain it
…then they don’t understand how the drug works, and shouldn’t be prescribing it to anyone.
I have it direct from an ob*sity medicine specialist at one of the country’s most prestigious universities — the GLP-1 doses approved for weight loss lower someone’s weight set point (the weight your body will comfortably settle at when you’re eating and exercising in a non-disordered way) while they are taking them. But if they stop taking the drug, their set point will revert to what it was before and they will regain any weight they lost.
The clinical trials that follow participants after they’re no longer on the medication bear this out — they regain the weight.
What if you are interested in a GLP1?
OK, let’s say you are potentially interested in taking one of these medications. Lots of people are, after all. I’m not going to lie, I have some concerns about them, but in the lower doses recommended for diabetes treatment, they’ve helped a lot of people.
That said, if you are considering taking a GLP-1 in the higher dose for weight loss, there are two primary things that I wish for you:
- That you have all the information you need to make a truly informed decision. Really understanding GLP-1 medications before taking one is important. Because if you consent to something, but you don’t fully know what you’re consenting to, are you really consenting?
- That you have the support you need to deal with any of the common side effects (nausea, constipation etc.) that you might experience, and to make sure that you are eating enough to meet your nutritional needs (more on this in a bit).
Let’s start with #1.
Let go of any magical thinking
Let’s start with the fact that GLP-1s are not magic. They’re medications/drugs that produce different results (including both weight loss and side effects) for different people.
Looking overall at the clinical trials for the GLP-1s currently approved for weight loss (so, at higher doses than what’s prescribed for diabetes), people lose between about 0% and 22% of their starting body weight.
That’s right, some people are “non-responders.” The drugs do nothing for them. Other people lose around one-fifth of their body weight.
Contrary to bad information floating around out there (including one irresponsible article on OprahDaily), people do not lose half of their body weight.
That means that the people these drugs are intended for, the people who are in a higher BMI class, will not become “thin” by taking these drugs.
Let’s do some math. If someone weighs 300 pounds and loses 20% of their starting weight, they will still weigh 240 pounds. Not thin. If they start out at 250 pounds, they will still weigh 200 pounds. Also not thin.
But what if they’re one of the many people who lose 5% of their starting weight. Then we’re looking at 290 pounds or 237.5 pounds. Not thin.
Also — and this is important — those clinical trials also had participants create a calorie deficit by cutting calories (aided, of course, by the reduction in appetite) and increasing exercise. That’s right, they were dieting AND taking the drugs.
In fact, I recently read an interview with an ob*sity medicine specialist from another prestigious university who said the purpose of these drugs is to make it possible for weight loss from diet/exercise/lifestyle to be maintained instead of regained.
Because it took the debut of these drugs to make the ob*sity medicine field finally admit out loud that diets don’t work.
Not hungry? You still need food
GLP-1s’ main actions — acting on the brain to reduce appetite and slowing stomach emptying to increase satiety — make it possible to diet without feeling hungry all the time or making your body go into starvation mode and start slowing your metabolism.
Now about that appetite. A few things to know:
- The most popular GLP-1 medications are longer-acting, requiring an under-the-skin (subcutaneous) injection only once per week. Some people find that their appetite flares towards the end of each week.
- Some people who need to stop taking the medication (more on that in a bit) find that their appetite comes roaring back in a way that I’ve heard described as a starving tiger or a tsunami. This can feel frightening.
- Some people find that the appetite-suppressing effects of the drug work a little too well, leaving them with virtually no appetite at all and/or forgetting to eat until they just end up grabbing a handful of popcorn.
Let’s talk about that last one. Even if you have no appetite, your body still needs fuel (calories) and nutrients. That’s true whether you have no appetite because you have the flu, you’re grieving, or you are on a GLP-1. Except with the first two you will get your appetite back much sooner.
Our cells need micronutrients (vitamins and minerals) to function. Our bones need nutrients to stay strong. Our muscles need protein to not wither. Your cells, bones and muscles don’t let go of those needs just because you don’t feel like eating. That’s true for anyone under any circumstance.
It can be tempting to think, “No appetite? I don’t have to bother to eat. Great!”
No, not great. And when this scenario happens, to protect your health one or both of these things needs to happen:
- Your doctor needs to lower your dose.
- You need to work with a registered dietitian to figure out how to meet your nutritional needs on fewer calories when you don’t really want to eat at all.
I looked this up, and the minimum recommended calories for a woman on these drugs is 1,200-1,500 calories. For men, it’s 1,500 to 1,800 calories. And when you’re eating this few calories, those calories need to REALLY count nutritionally.
(And, no, you can’t just pop a multivitamin. While that may provide some extra nutritional “insurance” when someone has trouble eating, isolated nutrients aren’t an effective 1-to-1 swap for nutrients from food.)
A registered dietitian can also help you deal with common side effects such as nausea and constipation by making the right food choices.
Some side effects are rare, but they can still happen
So let’s talk more about side effects. We’ve covered the most common ones (nausea, constipation, excessively low appetite + early satiety). You may have heard about other, scarier, side effects, such as paralyzed or blocked intestines, blindness, suicidal ideation.
I’ve dug through the most recent research, and it seems like suicidal ideation isn’t the concern it was initially thought to be (but anyone thinking about taking a GLP-1 should let their doctor know if they’ve suffered from depression). The eye thing appears to be extremely rare.
Gastroparesis
Gastroparesis is when your stomach becomes paralyzed. While the risk of this is relatively rare, it is four times higher when you’re taking a GLP-1. So is the risk of bowel obstruction. The risk of developing pancreatitis, which is when your pancreas becomes irritated and inflamed, is also nine times higher in GLP-1 users.
I will add, four times higher than what? Nine times higher than what? These are still rare in GLP-1 users, but they are all very serious side effects, and no one can just assume “Oh, that won’t happen to ME.” None of us are special unicorns to whom different rules apply. It’s just really important to assume that you could be one of the unlucky ones, and are you sufficiently at peace with that possibility? Again, that’s part of informed consent.
Hair loss and sagging skin
In the less serious, but still not fun camp of side effects are hair loss and sagging skin. Both of these can happen whenever someone loses a lot of weight, but it’s unclear if and when the hair grows back.
Also, contrary to some myths I’ve heard, these medications don’t also “shrink” your skin. So anyone who does lose a lot of weight on these drugs (and not everyone does), may need to consider plastic surgery if the excess skin is uncomfortable or otherwise problematic.
What if you stop taking a GLP-1 medication?
Part of informed consent is understanding that a lot of people who take GLP-1s stop taking them within a year. That’s more likely to happen with people who are taking the weight-loss doses (not the lower diabetes doses).
While estimates from the various research studies on this phenomenon vary, it hovers at about half of people who take the drug for weight loss only stopping within a year. Recent research has also shown that many people who stop do so before they’re even at the maximum dose and before they’ve reached whatever the maximum weight loss would be for them.
- Some people stop because even the common side effects (nausea, constipation) are not something they want to continue experiencing.
- Others might not see enough early weight loss to feel that it justifies staying on the drug (especially if they also have side effects).
- Still others stop because they lost access to the drug (they lost their insurance, changed jobs and insurances, etc.).
There’s also some B.S. with some insurance companies refusing to cover GLP-1s for weight loss anymore once someone reaches a weight that would not qualify them for the drug if they were seeking it for the first time. This is bananas, given that these medications are intended to be continued for life. And these drugs are expensive out-of-pocket.
Let’s consider all of this. What would you do if you chose to take a GLP-1, you lost weight, and you had to discontinue it for one of the reasons I mentioned? How would you cope with regaining the weight and possibly having a wicked rebound appetite?
Thinking this through is part of making an informed decision about whether to take one of these medications.
These drugs are not magic, Part 2
GLP-1 medications (at both diabetes doses and weight loss doses) have direct benefits for certain health conditions, such as cardiovascular disease and liver disease. They appear to also have benefits for reducing substance use disorder.
Other than the observed benefit for obstructive sleep apnea (which, yes, can be improved by weight loss in larger-bodied individuals, but can also be managed with a C-Pap machine), it appears that, again, these drugs have DIRECT effects on these conditions. In other words, the benefits aren’t due to weight loss.
So, a question to consider is: Do you have a health concern that GLP-1s would work directly on? If so, what are other treatment or prevention possibilities?
I have an acquaintance with a strong genetic predisposition to liver disease. Her father had to have a liver transplant. She’s in a slightly larger body and was not interested in losing weight. She started taking a lower dose of a GLP-1, and her liver enzymes reverted to normal levels. She said she was having some manageable side effects, but if being on that drug means she never has to have a liver transplant, it’s worth it. She also has polycystic ovary syndrome (PCOS), and it’s helped with that (not surprising, since GLP-1s were originally approved for type 2 diabetes, and PCOS is a related health condition).
I know other people who were offered a GLP-1 because they are in larger bodies and have a health condition that may be helped directly by the drug. They chose instead to have a conversation with their doctor about their current risk level, and what their other options are (including continued monitoring with preventive health screenings). They decided GLP-1s were not for them, at least not at this time.
Final thoughts + body image
Both scenarios above are examples of making an informed decision and giving informed consent, even though the eventual decisions were different.
That’s because informed consent is not blind consent. It’s not saying “yes” because your doctor wants you to. It’s not saying “yes” because you’re seduced by “before” and “after” photos of a celebrity or an everyday person who’s taking a GLP-1. It’s not saying “yes” on what you hope will happen when you really don’t know the range of possible outcomes and come to terms that you don’t really know what your personal outcome will be.
I so ardently want people to make the decision that’s right for them based on solid information that I wrote this really long article (2,713 words).
I also ardently want people who do choose to say “yes” to a GLP-1 weight loss medication to have the support they need to weather any possible storms of side effects and plummeting appetite. I want people to take care of their muscles and bones and get the nutrients they need to support their overall health, reduce risk of chronic disease, age healthfully, and all that jazz.
Body dissatisfaction
I also want people to know that if they struggle with body dissatisfaction, poor body image, whatever you want to call it, these medications don’t heal that. Even if you’re one of the people who lose 20% of your starting weight on a GLP-1, as weight loss slows and stops and you settle into your newly different body, the rumbles of dissatisfaction will probably grow louder. That’s because the way to heal a difficult relationship with your body isn’t to change your body, it’s to address the underlying wounds and beliefs that made that relationship difficult to begin with.
So if you say “yes” to a GLP-1 (or any form of weight loss), please make sure you also do the healing work.
Carrie Dennett, MPH, RDN, is a Pacific Northwest-based registered dietitian nutritionist, journalist, intuitive eating counselor, author, and speaker. Her superpowers include busting nutrition myths and empowering women and men to feel better in their bodies and make food choices that support pleasure, nutrition and health. This post is for informational purposes only and does not constitute individualized nutrition or medical advice.
Seeking 1-on-1 nutrition counseling? Learn more about her Food & Body, IBS management, and nutrition counseling programs, and book an intro call to see if the program is a good fit, and if we’re a good fit!
Want exclusive content on nutrition, health, diet culture and more, plus critiques of nutrition and health journalism? Subscribe to my Food Noise newsletter! 📣
Print This Post
nutritionbycarrie.com (Article Sourced Website)
#Understanding #GLP1 #medications #Nutrition #Carrie