My biggest GLP-1 ethical problem: patients who don’t want to stop

Status
Not open for further replies.

Calm Logic

GLP-1 Specialist
Member Since
Mar 24, 2025
Posts
3,206
Likes Received
7,967
Location
USA
My biggest GLP-1 ethical problem: patients who don’t want to stop

Some GLP-1 patients are begging to stay on the drugs just a little bit longer, presenting an ethical dilemma for doctors.

www.statnews.com

We’ve gone from weight loss drug shortages to a problem of excess — and eating disorders ​[archived internal link]
By Jody Dushay, MD

Feb. 19, 2026

...In my experience, people who take GLP-1 therapies fall into several categories.

The majority lose 10% to 20% of their body weight over six to 12 months and keep most of that weight off while continuing treatment; these are average responders.

About 5% do not respond to or tolerate any GLP-1 medication, meaning they have minimal or no weight loss or must stop treatment due to side effects.

Another approximately 5% of my patients are super responders who lose more than 25% of their body weight. I have seen as high as 45%. There are likely genetic underpinnings that explain at least in part why people do not respond or super respond to pharmacologic levels of GLP-1. Right now there are no simple blood tests we can do to predict degree of response.

Everyone eventually reaches a weight loss plateau at the maximum tolerated dose of GLP-1 treatment. And I have had very few people tell me that the plateau weight is their Goldilocks weight. It’s not uncommon for people to become so fixated on seeing a certain number on the scale that they lose sight of having made tremendous improvements in their overall health. Almost everyone wants more weight loss, and I am learning in real time how to best support patients who have reached a weight loss plateau at a weight that is higher than they hoped at the start of treatment. I feel like I’m asking someone who trained for a marathon to feel satisfied after completing 10 kilometers.

But what I am finding the most difficult is how to help people understand why I think they have lost too much weight, and why in some cases I insist on stopping or significantly lowering the dose of their GLP-1 treatment. It’s a really hard negotiation when someone proposes, “How about if I just stay on the same dose for another few months, in case I gain weight on vacation/after menopause/over the holidays?”

As an endocrinologist, I am not professionally trained to treat eating disorders or disordered eating, but I know both when I see them, and I am unfortunately seeing them more often.

GLP-1 therapies are without a doubt life-changing for people with intrusive cravings, nonstop thoughts about food, and a blunted sensation of fullness. At the same time, complete lack of appetite is abnormal and beyond what GLP therapies should do. The same is true about fear of food and fixation on a certain weight. When there is stress at home at mealtime, when friendships are strained because it is uncomfortable to meet socially if food is involved, or when a partner, child, or parent thinks someone has developed very abnormal eating habits, these are all red flags.

Some of my patients minimize the side effects of GLP-1 medication because they don’t want to lower their dose or stop taking it, which can lead to serious complications. Although I do not routinely measure longitudinal change in body composition or bone mass in people taking GLP-1s, mostly because of the cost of DXA scans, significant muscle or bone loss are two objective manifestations of excessive weight loss that should lead to stopping or slowing treatment.

To be sure, I respect that weight loss is a struggle for these patients, and I prescribe and advocate for medication to help people lose weight.

But I am also responsible when a physical or mental health threshold has been crossed. We live in a society where weight is seen as a readout of health, which is as inaccurate as it is unfortunate. Weight and BMI are only one metric of physical and emotional health. Just as important are what a person puts into and does with their body at any weight. The cutoffs for healthy weight based on body mass index (BMI) are plagued by the shortcomings of BMI itself, which should not be used as the only determinant of complicated obesity.

So how do I decide in the moment if a person in front of me is at a healthy weight? I use a collection of objective measurements such as cholesterol levels, blood pressure, waist size, blood sugar, and liver function to support my clinical judgement. I also ask patients what they eat over the course of a typical day, how much physical activity they get, and if they have enough energy to do things they enjoy...

At the start of treatment, I want to understand why a person wants to lose weight, and I avoid setting a numeric weight loss goal. There is such thing as too much weight loss, and I hope this does not become something I see more often as a consequence of GLP-1 therapies.
 
I wish I could be one of the 45% super reponders. I lost 34% and an still overweight by BMI. I'm 5’6” and now weigh 215. My wife thought I looked to thin in 2008 when I lost 40 pounds and got down to 180. So my goal was 190. I've been stalled since around may 2025. I'm currently stacking 1mg Sema and 5mg Reta trying to get the scale moving down again. It appears to be working slowly.
 
I understand that this was written by a working endocrinologist trying to work these issues out in clinical practice without a huge amount of scientific research about what to do after weight loss has occurred, on these medications to guide decision making.

I get the impression his thinking is strongly influenced by what was possible and healthy in the past in terms of weight loss, where a 5-10% weight loss that could be maintained was an excellent result, in terms of improved health outcomes.

The reality is that that has changed, and much better outcomes are now realistic, not for everyone, as some people cannot tolerate them or respond poorly. But for a lot of people 20% weight loss is quite realistic. I am continually surprised at how few people I see on this forum who are stuck halfway to their goals, after losing 20% or so of their weight, from the studies this should be almost everyone who is more severely overweight. Even with a selected population , peptide stacking and multiple GLP's this should be more common, but it is not.

There is a place for the concerned paternalistic attitude he expresses, using these medications without medical supervision or advice carries extra risks , independent of any risks of contaminated or mislabelled or fake products. And people do get themselves hospitalised quite often from dosing errors from the diy approach, but this attitude is inherently oppositional to a patients or persons right to chose their medical decisions for themselves, and medicine has always been pretty bad at dealing with this issue. Clearly taking GLP's when suffering from anorexia nervosa is not a good idea, but I think I would be drawing that line between patient autonomy and paternalism a lot closer to the autonomy side than he does.

I think the evidence of long term health outcomes in the severely obese , diabetics or people with heart disease are very clear, they substantially improve health, and there is good scientific evidence that this benefit is greater at higher rather than lower therapeutic doses, which calls into question the medical basis for stopping or reducing doses in some of his patients, as the evidence is also clear that stopping these medications or reducing their doses will cause weight regain, with consequent negative health effects.

In terms of deciding about treatment on the basis of his assessment of its effects on quality of life, again in general the best person to be deciding is the person themselves, with a few exceptions in case of severe eating disorders.

Most Doctors in my experience are just as bigoted as the general population towards people with severe obesity, this doctor does not seem to be showing this, but he is very unlikely to have anything like a full understanding of a persons experience of being in that state. Severe obesity is associated with severe social consequences, lower income, being looked at as subhuman by strangers and these effects more than the health ones drive people to want to lose weight. In less severe obesity the consequences are not as great but nowhere near insignificant.

I think he is failing to comprehend the full picture of life experienced by his patients, which leads him to err on the side of excessive caution in using these medications.

Before GLP's were available an amazingly small percentage of the population ever succeeded in massive weight loss long term, and those few that did had to massively change their lives and obsessively control eating and exercise. Yet he is choosing to stop medication when it interferes with social aspects of eating. Keeping large amounts of weight off long term requires fairly obsessive control over what foods you eat, when most people around you are eating unhealthy diets, if you wish to not eat the same foods it is always going to cause some problems with shared eating.

I do not think I would remain his patient for long , losing 54% of my weight , and eating a highly restricted repetitive diet, sounds a lot like his red flags, yet this is exactly what is required to maintain that weight loss ( plus a bit of reta as well as 15mg of tirzepatide)

Given the fairly easy availability of much much cheaper pirate Chinese GLP's, his attitude could push those persons who he believes need to be on lower doses or stop , who do not agree with his decisions into the grey market.

Looking at the way this market has grown over the past year or so, it is going to get much much bigger in the future, the pent up demand from literally billions of people with obesity who would prefer to be less overweight is enormous, and then there are all those who are a bit overweight and would prefer to be thinner for pretty reasonable social reasons ( society judges people for being fat, and quite a lot ). The costs of the legit versions are so high that a black market was completely inevitable, and though I think prices will become more reasonable in several years time as competition increases, I think that this sort of overly paternalistic medical attitude pushes people away from the medical approach and towards the grey or black market. And that does carry some extra risks mainly from neglect of other related medical issues like optimal treatment of blood lipids , diabetes and pre diabetes and hypertension, as well as exposure and possible use of a whole other set of peptides, that mostly have zero human clinical trials that demonstrate that they work or are safe.
 
I understand the problem from the patient's perspective and the problem from the doctor's perspective.

I lost 30% of my weight within a year with Mounjaro and am now on maintenance.

I should really be gradually reducing the dosage to avoid losing more weight while eating normally.

To prevent further weight loss, I'm now eating more high-calorie foods and maintaining my weight that way.

I just can't bring myself to reduce the dosage.

I think it's a mental thing.
 
lessthanhalf said:
I understand that this was written by a working endocrinologist trying to work these issues out in clinical practice without a huge amount of scientific research about what to do after weight loss has occurred, on these medications to guide decision making.

I get the impression his thinking is strongly influenced by what was possible and healthy in the past in terms of weight loss, where a 5-10% weight loss that could be maintained was an excellent result, in terms of improved health outcomes.

The reality is that that has changed, and much better outcomes are now realistic, not for everyone, as some people cannot tolerate them or respond poorly. But for a lot of people 20% weight loss is quite realistic. I am continually surprised at how few people I see on this forum who are stuck halfway to their goals, after losing 20% or so of their weight, from the studies this should be almost everyone who is more severely overweight. Even with a selected population , peptide stacking and multiple GLP's this should be more common, but it is not.

There is a place for the concerned paternalistic attitude he expresses, using these medications without medical supervision or advice carries extra risks , independent of any risks of contaminated or mislabelled or fake products. And people do get themselves hospitalised quite often from dosing errors from the diy approach, but this attitude is inherently oppositional to a patients or persons right to chose their medical decisions for themselves, and medicine has always been pretty bad at dealing with this issue. Clearly taking GLP's when suffering from anorexia nervosa is not a good idea, but I think I would be drawing that line between patient autonomy and paternalism a lot closer to the autonomy side than he does.

I think the evidence of long term health outcomes in the severely obese , diabetics or people with heart disease are very clear, they substantially improve health, and there is good scientific evidence that this benefit is greater at higher rather than lower therapeutic doses, which calls into question the medical basis for stopping or reducing doses in some of his patients, as the evidence is also clear that stopping these medications or reducing their doses will cause weight regain, with consequent negative health effects.

In terms of deciding about treatment on the basis of his assessment of its effects on quality of life, again in general the best person to be deciding is the person themselves, with a few exceptions in case of severe eating disorders.

Most Doctors in my experience are just as bigoted as the general population towards people with severe obesity, this doctor does not seem to be showing this, but he is very unlikely to have anything like a full understanding of a persons experience of being in that state. Severe obesity is associated with severe social consequences, lower income, being looked at as subhuman by strangers and these effects more than the health ones drive people to want to lose weight. In less severe obesity the consequences are not as great but nowhere near insignificant.

I think he is failing to comprehend the full picture of life experienced by his patients, which leads him to err on the side of excessive caution in using these medications.

Before GLP's were available an amazingly small percentage of the population ever succeeded in massive weight loss long term, and those few that did had to massively change their lives and obsessively control eating and exercise. Yet he is choosing to stop medication when it interferes with social aspects of eating. Keeping large amounts of weight off long term requires fairly obsessive control over what foods you eat, when most people around you are eating unhealthy diets, if you wish to not eat the same foods it is always going to cause some problems with shared eating.

I do not think I would remain his patient for long , losing 54% of my weight , and eating a highly restricted repetitive diet, sounds a lot like his red flags, yet this is exactly what is required to maintain that weight loss ( plus a bit of reta as well as 15mg of tirzepatide)

Given the fairly easy availability of much much cheaper pirate Chinese GLP's, his attitude could push those persons who he believes need to be on lower doses or stop , who do not agree with his decisions into the grey market.

Looking at the way this market has grown over the past year or so, it is going to get much much bigger in the future, the pent up demand from literally billions of people with obesity who would prefer to be less overweight is enormous, and then there are all those who are a bit overweight and would prefer to be thinner for pretty reasonable social reasons ( society judges people for being fat, and quite a lot ). The costs of the legit versions are so high that a black market was completely inevitable, and though I think prices will become more reasonable in several years time as competition increases, I think that this sort of overly paternalistic medical attitude pushes people away from the medical approach and towards the grey or black market. And that does carry some extra risks mainly from neglect of other related medical issues like optimal treatment of blood lipids , diabetes and pre diabetes and hypertension, as well as exposure and possible use of a whole other set of peptides, that mostly have zero human clinical trials that demonstrate that they work or are safe.
I understand your argument and your perspective. Interestingly, I do not read the article as paternalistic. Rather, it reads to me like a physician mindful of the Hippocratic Oath to which physicians are ethically bound. I read a struggle between supporting or even encouraging this class of medications and the array of outcomes for incredible success rates. Body dysmorphia is real. Disordered eating is real.

People for whom a life free of obesity was complete fantasy are now undergoing physical metamorphoses in previously unimaginable ways. It isn't a far reach from discovering a good thing to overusing that good thing.

I don't know this physician so I don't know his agenda, his bedside manner, or his philosophy. I do know it is very possible for them to be genuinely concerned about what their patients may be facing and to want to figure out how to continue supporting their good health as an ethical medical professional.

There is a LOT more I want to say but it quickly becomes too revealing in a place I prefer to be unknown rather than discoverable. No, I am not a physician.
 
The eating disorder issue is a tough one. I'm not sure that the GLP's are causing some eating disorders or are just used as a tool for those who have the disorder.

The over-eating of food long term was killing me. And food was my drug. But under-eating of food can also kill.

But just like we have the freedom to over-eat, folks have the freedom to under-eat as well.

I can understand a Doc not wanting to contribute to anyone "feeding" any extreme.

But here in the Grey, no one can stop the "prescription". Likewise, no one could've stopped me from buying and eating when I had a food addiction.
 
MeedzMoar said:
I understand your argument and your perspective. Interestingly, I do not read the article as paternalistic. Rather, it reads to me like a physician mindful of the Hippocratic Oath to which physicians are ethically bound. I read a struggle between supporting or even encouraging this class of medications and the array of outcomes for incredible success rates. Body dysmorphia is real. Disordered eating is real.

People for whom a life free of obesity was complete fantasy are now undergoing physical metamorphoses in previously unimaginable ways. It isn't a far reach from discovering a good thing to overusing that good thing.

I don't know this physician so I don't know his agenda, his bedside manner, or his philosophy. I do know it is very possible for them to be genuinely concerned about what their patients may be facing and to want to figure out how to continue supporting their good health as an ethical medical professional.

There is a LOT more I want to say but it quickly becomes too revealing in a place I prefer to be unknown rather than discoverable. No, I am not a physician.

I had both of your thoughts initially after reading. Then when I thought about it more I realized that as an endocrinologist (that I assume is practicing in the US), he's likely using coded language and doesn't even realize how it's influencing the position he's offering:

Although I'm sure he has a malpractice policy, he's still going to want to avoid creating potential legal liability for himself or his clinic first and foremost. He won't admit it, but that's going to be a higher priority than optimal patient care, in the event that the two conflict. In the extreme case, if a patient with a BMI of 15 were to come to him and demand a higher GLP dose, it's conceivable that were he to honor that request, he could find himself forced to defend that decision as part of a lawsuit down the road, in the event something happened that could be framed as a result of such a treatment decision.

However, in discussing with a patient, a doctor is very rarely going to say "I'd love to honor your request, but you could sue me later so I won't." Instead, they'll code it as if the decision is their own personal medical judgement and over time he may even come to believe that's the driving force. Years of doing that will have him in the habit of explaining restrictions using that sort of language to the point where in writing an article like this he'll use such an asinine and inflammatory framing, as it better fits his persona than admitting he just doesn't want to get sued if he can help it.
 
Nmcoyote1 said:
I wish I could be one of the 45% super reponders. I lost 34% and an still overweight by BMI. I'm 5’6” and now weigh 215. My wife thought I looked to thin in 2008 when I lost 40 pounds and got down to 180. So my goal was 190. I've been stalled since around may 2025. I'm currently stacking 1mg Sema and 5mg Reta trying to get the scale moving down again. It appears to be working slowly.
I have somewhat of the same dilemma - GW and "too thin" reached me before BMI was at healthy rather than "overweight." I'm 5'-11" and down to 185 lbs. BMI is still "overweight" by a few pounds. I'm totally focused on cardiovascular concerns so I see my BMI and become apprehensive AND my girlfriend looks at me and says that I am getting way too thin. I look in the mirror and see that she is not wrong.

SOOOOOOOO........ I use a different/newer method for assessing my overall weight health: Waist/Hip Ratio (WHR - look it up) instead of BMI. WHR for males should be approx .90. I am at .98. However, I genetically don't have much of a butt - never have - SO I am doing what I can to enlarge my butt rather than shrink my waist anymore - which means I am doing A LOT of heavy hip thrusts at the gym. 🙂 LOL - and it is beginnning to payoff. Went up 1/4" in my butt in the past 2 months. Waist hasn't changed.
 
randompersonrandom said:
It's weird to see them talk about "stopping" like that's not going to result in a regain when we more or less KNOW it is. The lowering, ok, but stopping? Why, so you can do this all over again in a year?
Do you think this bunch, us on this forum, even exsist? According to practicing and licensed doctors. We've got tons of data because we are our own counselors. But I don't think any doc could even legally be here to glean this, our, info. 🤔
 
randompersonrandom said:
It's weird to see them talk about "stopping" like that's not going to result in a regain when we more or less KNOW it is. The lowering, ok, but stopping? Why, so you can do this all over again in a year?
That's just because GLPs for obesity are a newer approved treatment mode. Pharma knows that more people will accept GLPs if their perception is "take this for a few months, lose the weight, and be done," so they don't push maintenance hard right now. For now it's more about getting their foot in the door in terms of getting health plans to pay for these drugs and it's a much easier sell if they can frame it as short-term.

Once they feel GLPs have reached critical mass for weight loss use and health plan coverage, pharma will push endocrinologists in whatever professional societies are applicable to start issuing positions on maintenance care, since at that point it will be harder for health plans to reverse course on coverage and they'll be stuck paying for life (and the higher premiums that come with that).
 
rpm2026 said:
I certainly do not want to stop taking glps and I have hit my goal weight. I am struggling to figure out what is a good maintenance dose. I find that I am appalled by feeling hungry.
I don't plan on ever stopping either. I can eat on Tirz if I want. I'm stalled at the moment. So there's that... But I could even gain weight on it if I wanted to. Tirz gives me the ability to control what I want or need. And the ability to choose only what I need instead is a huge win 🙂
 
Candaril said:
To prevent further weight loss, I'm now eating more high-calorie foods and maintaining my weight that way.

Zydeceltico said:
I have somewhat of the same dilemma - GW and "too thin" reached me before BMI was at healthy rather than "overweight." I'm 5'-11" and down to 185 lbs. BMI is still "overweight" by a few pounds.
We don't need your glowing successes ruining our enjoyment of broccoli sandwiches, haha.

lessthanhalf said:
I do not think I would remain his patient for long , losing 54% of my weight , and eating a highly restricted repetitive diet, sounds a lot like his red flags, yet this is exactly what is required to maintain that weight loss ( plus a bit of reta as well as 15mg of tirzepatide)
I did find the doctor's comment about social gatherings to be odd too, since a lot of diets (including religious and ethical ones) are already anti-social like vegan diets.
 
Sasquatch said:
Do you think this bunch, us on this forum, even exsist? According to practicing and licensed doctors. We've got tons of data because we are our own counselors. But I don't think any doc could even legally be here to glean this, our, info. 🤔

tubby said:
That's just because GLPs for obesity are a newer approved treatment mode. Pharma knows that more people will accept GLPs if their perception is "take this for a few months, lose the weight, and be done," so they don't push maintenance hard right now. For now it's more about getting their foot in the door in terms of getting health plans to pay for these drugs and it's a much easier sell if they can frame it as short-term.

Once they feel GLPs have reached critical mass for weight loss use and health plan coverage, pharma will push endocrinologists in whatever professional societies are applicable to start issuing positions on maintenance care, since at that point it will be harder for health plans to reverse course on coverage and they'll be stuck paying for life (and the higher premiums that come with that).

Yeah, but...SURMOUNT happened. Everybody saw it happen. They're out there just pretending it's not real, but it was, and that's wild to me.
 
There are other things that GLPs bring to the table in addition to weight loss. The elimination of the desire for alcohol is probably just behind my weight loss in a rating of importance to me. Other bad habits have fallen by the wayside since starting Reta. I've always said that I will keep some around for the rest of my life just because of this effect, and that's even if I was to maintain a healthy weight without it, which is unlikely also.
 
Calm Logic said:
My biggest GLP-1 ethical problem: patients who don’t want to stop

Some GLP-1 patients are begging to stay on the drugs just a little bit longer, presenting an ethical dilemma for doctors.

www.statnews.com

We’ve gone from weight loss drug shortages to a problem of excess — and eating disorders ​
By Jody Dushay, MD

Feb. 19, 2026

...In my experience, people who take GLP-1 therapies fall into several categories.

The majority lose 10% to 20% of their body weight over six to 12 months and keep most of that weight off while continuing treatment; these are average responders.

About 5% do not respond to or tolerate any GLP-1 medication, meaning they have minimal or no weight loss or must stop treatment due to side effects.

Another approximately 5% of my patients are super responders who lose more than 25% of their body weight. I have seen as high as 45%. There are likely genetic underpinnings that explain at least in part why people do not respond or super respond to pharmacologic levels of GLP-1. Right now there are no simple blood tests we can do to predict degree of response.

Everyone eventually reaches a weight loss plateau at the maximum tolerated dose of GLP-1 treatment. And I have had very few people tell me that the plateau weight is their Goldilocks weight. It’s not uncommon for people to become so fixated on seeing a certain number on the scale that they lose sight of having made tremendous improvements in their overall health. Almost everyone wants more weight loss, and I am learning in real time how to best support patients who have reached a weight loss plateau at a weight that is higher than they hoped at the start of treatment. I feel like I’m asking someone who trained for a marathon to feel satisfied after completing 10 kilometers.

But what I am finding the most difficult is how to help people understand why I think they have lost too much weight, and why in some cases I insist on stopping or significantly lowering the dose of their GLP-1 treatment. It’s a really hard negotiation when someone proposes, “How about if I just stay on the same dose for another few months, in case I gain weight on vacation/after menopause/over the holidays?”

As an endocrinologist, I am not professionally trained to treat eating disorders or disordered eating, but I know both when I see them, and I am unfortunately seeing them more often.

GLP-1 therapies are without a doubt life-changing for people with intrusive cravings, nonstop thoughts about food, and a blunted sensation of fullness. At the same time, complete lack of appetite is abnormal and beyond what GLP therapies should do. The same is true about fear of food and fixation on a certain weight. When there is stress at home at mealtime, when friendships are strained because it is uncomfortable to meet socially if food is involved, or when a partner, child, or parent thinks someone has developed very abnormal eating habits, these are all red flags.

Some of my patients minimize the side effects of GLP-1 medication because they don’t want to lower their dose or stop taking it, which can lead to serious complications. Although I do not routinely measure longitudinal change in body composition or bone mass in people taking GLP-1s, mostly because of the cost of DXA scans, significant muscle or bone loss are two objective manifestations of excessive weight loss that should lead to stopping or slowing treatment.

To be sure, I respect that weight loss is a struggle for these patients, and I prescribe and advocate for medication to help people lose weight.

But I am also responsible when a physical or mental health threshold has been crossed. We live in a society where weight is seen as a readout of health, which is as inaccurate as it is unfortunate. Weight and BMI are only one metric of physical and emotional health. Just as important are what a person puts into and does with their body at any weight. The cutoffs for healthy weight based on body mass index (BMI) are plagued by the shortcomings of BMI itself, which should not be used as the only determinant of complicated obesity.

So how do I decide in the moment if a person in front of me is at a healthy weight? I use a collection of objective measurements such as cholesterol levels, blood pressure, waist size, blood sugar, and liver function to support my clinical judgement. I also ask patients what they eat over the course of a typical day, how much physical activity they get, and if they have enough energy to do things they enjoy...

At the start of treatment, I want to understand why a person wants to lose weight, and I avoid setting a numeric weight loss goal. There is such thing as too much weight loss, and I hope this does not become something I see more often as a consequence of GLP-1 therapies.
I am one of the people this article is about.
 
Status
Not open for further replies.

Trending content

Members online

No members online now.

Forum statistics

Threads
2,419
Messages
51,228
Members
1
Latest member
Admin
Back
Top