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

[igottapee]

I always get the most pushback when I tell people "changing your lifestyle" is also the main goal. No one wants to put in the hard work of diet and exercise. With those, you will get the real benefits!

 

[Calm Logic]

I always get the most pushback when I tell people "changing your lifestyle" is also the main goal.

For good reason? GLPs help with the biological signals (crazy hunger or food noise) that can even make it hard to think. Hard to make permanent lifestyle changes when your body is in an alarmed/altered state. And everyone on GLPs has dieted and exercised before. I don't see GLPs as just a tool. But rather as a necessary, lifelong medication.

Yes, a healthier diet will help, as will exercise, and those things can help with bloodwork (as do GLPs), blood pressure (as do GLPs), and having a lower maintenance dose. And, of course, resistance training will help prevent losing muscle:

Factor Benefit Note Zone 2 Cardio Mitochondrial biogenesis & fat oxidation 45–60 mins at "conversational" pace to trigger PGC-1α and maximize fuel efficiency. Resistance Training Preserves Lean Body Mass (LBM) Prevents "skinny fat" outcome during rapid weight loss; aim for 2–3 sessions per week. Plant-Based Diet Cardiovascular & Gut Health High fiber and low saturated fat; essential for managing LDL and endothelial function. GLP-1s Appetite control & BP regulation Acts as the "metabolic bridge" to make intensive lifestyle changes sustainable. Maintenance Sustainability & Safety Titrating to the lowest effective dose reduces side effects like gastric slowing.

 

[Grogu]

I don't see GLPs as just a tool. But rather as a necessary, lifelong medication.

The medical community increasingly recognizes obesity as a chronic medical condition, not a personal failing. Society is still catching up.

In my case, GLP-1 therapy addresses an underlying metabolic dysfunction. If I discontinue treatment, I would expect to return to my prior baseline. But I’ve lived with obesity my entire life and have struggled with it for decades. While others with less metabolic dysregulation may be able to maintain results without medication, I know that for me, long-term therapy is necessary.

 

[lessthanhalf]

I know exactly how hard it is to maintain massive weight loss without GLP's. I got down to 65kg in 2013 from 120 or 130 kg and stayed there for 2 years. But eventually I just could not stick to eating the types of foods that I needed to eat and the usual just one serve of ice cream won't hurt logic and where that ends up for me at least.

And I did it again in 2022 - 2023 from 145 to 75kg and kept it off for a year.

After starting semaglutide , I think for the first time in my life I experienced being too full to finish eating what I had put on my plate. I put up with feeling nauseous and a bit ill for a year in exchange for being less hungry then thankfully discovered cheaper Chinese options with both better appetite suppression and less side effects.

Much to my surprise I am still very slowly losing weight 100-200g per week, without constant conscious effort to eat less than I want. At 66kg and bmi of 24, I am not entirely sure where to stop. I will eventually reach a point on current doses where weight loss stops or I will just have to pick a weight and drop doses of reta and tirz a little, or drop some of the other peptides I have added in for additional possible effects on appetite/weight - Adamax for alpha MSH, low dose HGH, oxytocin, and mots-c. Despite the underlying receptor effects being reasonably well understood, I have no real idea how effective any of these actually are, given that none have ever been studied in humans for weight loss, will have to stop them at some point and see what happens to weight or hunger. No intention of ever stopping Tirzepatide or Reta.

 

[randompersonrandom]

For good reason? GLPs help with the biological signals (crazy hunger or food noise) that can even make it hard to think. Hard to make permanent lifestyle changes when your body is in an alarmed/altered state. And everyone on GLPs has dieted and exercised before. I don't see GLPs as just a tool. But rather as a necessary, lifelong medication.

Hear hear. I don't argue with people who spout "you have to change your lifestyle!" because I don't argue online unless I'm being paid money for it, and I don't argue in regular life because there are so many people who would like to talk to me that I could never make enough time or energy to talk as much with all of them as I'd like to, so I have to save my talking-with for people who aren't parroting stuff that's oversimplified and dull.

But yeah, Patricia, of course I have to "change my lifestyle" to lose weight and keep it off. But that's not a button you push once, or once a month, and say "YAY, LIFESTYLE CHANGED" and then move on. That's a constant upkeep that sounds super inspirational when you say it like that but actually means "eat less food than I badly want, all day, every day, forever, while ignoring my deep desire to eat the amount of food that I badly want" because we all know you can't outrun your fork. So ok, Patricia, these meds allow me to "change my lifestyle" and we're all happy, what are you babbling about?

(that said, hooray for those unicorns who are able to use these meds to jump start and then remain in the habit once they've lived in it long enough. That isn't me and I don't believe it ever will be, but good on you if it IS you.)

 

[lessthanhalf]

Almost everyone on this forum has lost weight at some point in the past without GLP's. It is not super hard, you just have to decide to stick to a diet and stick to it and nearly everyone can do that for a while.

The problem with the "change you lifestyle" solution is not that it cannot work, but that it takes constant mental effort. Realistically if you were able to maintain that lifestyle/diet without a lot of constant mental work, you would not be obese. And eventually almost everyones' ability to put that effort in slowly wears away . If you succeed in establishing new habits that don't require that constant effort then you have solved the problem, but the reality of the research and most people's experiences says this is so hard that very few succeed. If your appetite regulation system cannot cope with constant cheap available high calorie highly rewarding food that it never evolved to deal with, then the only way not to eat too much is with constant effort and eventually that runs out.

Thankfully GLP's do not require constant effort for them to work, just injecting a medication once a week or so. Which bypasses that whole problem, and actually makes making and keeping to real meaningful long term lifestyle changes much easier and more likely. Simple example it is so much easier to exercise when not morbidly obese. So stopping them once at a goal weight actually puts those beneficial lifestyle changes as well as the weight loss at risk. I am not saying no one should ever try stopping them, but in severe longstanding obesity, I think it is a bad idea.

 

[tubby]

One bit of nuance that I feel is being missed here is that it's assumed that while all diets will require some degree of restriction, not all diets require fighting against hunger.

The standard "low calorie" approach is probably the most miserable and guaranteed to fail (in all but rare circumstances). That's because if you just keep eating the same highly palatable and addictive slop that you have been eating, only limiting yourself to 30% less per day until you relent. For those who only got as far as this approach then one can be forgiven for believing that the concept of dieting is completely unworkable.

Slightly less miserable is the world of low-fat diets, which usually include a stronger focus on things that resemble plants and less highly-refined grains. There's an initial hump to overcome some of the withdrawal-like qualities of giving up your favorite processed foods. You can feel full on a diet like this while losing weight, although satiety may remain elusive. And you won't feel hungry, just a sense of missing certain other foods and the feelings associated with them.

Less miserable than that (although many will disagree) are all of the different categories of low-carb diets, with some focusing towards being more or less meat-based, others focused towards plants and/or dairy, and some focusing more towards high-fat. I personally found these to be the easiest to to lose and maintain weight loss with, but man did I miss potatoes!

Then there were fasting tweaks one could add to these diets too, which probably sounds insane to those who haven't tried it (isn't that the definition of hunger, after all), which could be time restricted eating or regular days off from eating.

Every single one of these required giving something up, but many avoided the problem of continual hunger.

 

[lessthanhalf]

I do not disagree at all with the concept of trying to find a way of eating that controls hunger and allows you to eat enough food that you are not constantly restricting how much food you eat, mainly as that is just hard and usually fails eventually.

Ketogenic or low carb or even the ancient Atkins diet I remember trying a long time ago, has the advantage that the ketones suppress appetite and the lack of fluctuations in blood sugar, insulin and several dozen other appetite regulating hormones and neurotransmitters make it easier to stick to and prevent severe spikes in hunger that make loss of self control much more likely. I think in some respects Atkins got some of his thinking right even if it is nowhere near as simple as he thought. It is interesting that recently continuous glucose monitors often show spikes in sugar from high calorie foods followed by dips that then cause increased hunger, pretty much what Atkins thought was happening 40 years ago.

The hard part is that a high fat diet is a more likely to be high caloric density diet , which means small amounts of food, which does not help the hunger issue. Also the science on ketogenic diets seems to have changed many times over the past few decades as to whether they are healthy or not. But usually lack enough fiber and plant based foods.

The diet with by far the best science behind it in terms of preventing disease is the mediterranean diet, or variations on that theme.

My personal theory for obesity is sort of simple , low calorific density, less than 1.5 kcal/g is the main thing so you can eat as much as you want or need to eat to not be hungry, and if you can include a good percentage of protein in it then even better. Nearly all processed foods are too high in calorific density and it excludes nearly all high carb foods like bread and grain products, but does allow pretty much unlimited fruit and vegetables, even if they are mostly carbs or sugar it is bound up in cellular structures and fiber so is absorbed much more slowly than from foods like bread or biscuits. And it allows you to snack all day long on fruit, maybe not bananas, but a kilo of fruit is only 500 kcal or less usually and quite a lot to eat over a day. Very lean meat works and is the most effective suppressant of appetite per calorie.

It is hard to fit fat into this, even fairly small amounts automatically drastically increase the calories per gram. And the number of extra calories from small amounts of added fats can be large, 55 grams of oil having similar calories to a kilo of fruit. If that was all I could eat for a day I would be picking the fruit over the oil. A super low fat diet is not necessarily unhealthy but should ideally have some fish and olive oil in it. Given that I seem to have to maintain an intake that is less than an average 66kg 58yo male to maintain weight of 1600-1800 kcal/day, due to metabolic adaptation to long term calorie restriction, I don't have a lot of room to move to add calories in. There are quite a lot of studies supporting ideas in this way of eating, but it is nowhere near the standard viewpoint.

One of the problems is that I have found is that I need to be very careful about eating anything that might upset this system. Eating small amounts of rich food is going to mess up your preferences, so that lower calorie foods no longer taste as good, and risks those spikes in hunger that are difficult to control.

 

[Calm Logic]

Every single one of these required giving something up, but many avoided the problem of continual hunger.

That's how I think about it. If the standard/bad American diet is meat and potatoes, then some diets will restrict the meat (and other animal proteins) and some will restrict the potatoes (and bread and rice). The middle path is the Mediterranean diet, favored by the American Heart Association:

Diet Pattern AHA Score / Tier Why it Earned This Rating Mediterranean 89 / Tier 1 The Middle Path: High alignment with AHA goals. It lost a few points only because it doesn't explicitly limit salt and allows for moderate alcohol. Plant-Based (Vegan) 78 / Tier 2 Restricts the Meat: Excellent for fiber and low saturated fat, but Tier 2 because its restrictiveness can make it hard to follow long-term and may lead to B12 deficiency. Very Low-Fat (McDougall/Pritikin) 72 / Tier 3 Restricts the Meat & Fats: While it lowers LDL, the AHA docked points because it excludes healthy fats (nuts/olive oil) and can be too restrictive for the general public. Paleo 53 / Tier 4 Restricts the Potatoes: Failed because it excludes legumes and whole grains (fiber/nutrients) and does not limit saturated fats from meat. Keto (Very Low Carb) 31 / Tier 4 Total War on Potatoes: The lowest rating. The AHA cites the extreme restriction of fruits and grains, which leads to low fiber and high saturated fat intake.

And, of course: "Two people can eat the same food and have very different hormonal responses."

 

[tubby]

I do not disagree at all with the concept of trying to find a way of eating that controls hunger and allows you to eat enough food that you are not constantly restricting how much food you eat, mainly as that is just hard and usually fails eventually.

Ketogenic or low carb or even the ancient Atkins diet I remember trying a long time ago, has the advantage that the ketones suppress appetite and the lack of fluctuations in blood sugar, insulin and several dozen other appetite regulating hormones and neurotransmitters make it easier to stick to and prevent severe spikes in hunger that make loss of self control much more likely. I think in some respects Atkins got some of his thinking right even if it is nowhere near as simple as he thought. It is interesting that recently continuous glucose monitors often show spikes in sugar from high calorie foods followed by dips that then cause increased hunger, pretty much what Atkins thought was happening 40 years ago.

The hard part is that a high fat diet is a more likely to be high caloric density diet , which means small amounts of food, which does not help the hunger issue. Also the science on ketogenic diets seems to have changed many times over the past few decades as to whether they are healthy or not. But usually lack enough fiber and plant based foods.

The diet with by far the best science behind it in terms of preventing disease is the mediterranean diet, or variations on that theme.

My personal theory for obesity is sort of simple , low calorific density, less than 1.5 kcal/g is the main thing so you can eat as much as you want or need to eat to not be hungry, and if you can include a good percentage of protein in it then even better. Nearly all processed foods are too high in calorific density and it excludes nearly all high carb foods like bread and grain products, but does allow pretty much unlimited fruit and vegetables, even if they are mostly carbs or sugar it is bound up in cellular structures and fiber so is absorbed much more slowly than from foods like bread or biscuits. And it allows you to snack all day long on fruit, maybe not bananas, but a kilo of fruit is only 500 kcal or less usually and quite a lot to eat over a day. Very lean meat works and is the most effective suppressant of appetite per calorie.

It is hard to fit fat into this, even fairly small amounts automatically drastically increase the calories per gram. And the number of extra calories from small amounts of added fats can be large, 55 grams of oil having similar calories to a kilo of fruit. If that was all I could eat for a day I would be picking the fruit over the oil. A super low fat diet is not necessarily unhealthy but should ideally have some fish and olive oil in it. Given that I seem to have to maintain an intake that is less than an average 66kg 58yo male to maintain weight of 1600-1800 kcal/day, due to metabolic adaptation to long term calorie restriction, I don't have a lot of room to move to add calories in. There are quite a lot of studies supporting ideas in this way of eating, but it is nowhere near the standard viewpoint.

One of the problems is that I have found is that I need to be very careful about eating anything that might upset this system. Eating small amounts of rich food is going to mess up your preferences, so that lower calorie foods no longer taste as good, and risks those spikes in hunger that are difficult to control.

I love that you took the time to write that out and so much of that is really good and insightful information. Most of that I completely agree with or only disagree with in minor ways (like I might have a different cut-off on good "fruits" and we'd both be just as correct, since it's more of an opinion thing). I especially liked that you properly contextualized fruits and vegetables in-tact cellular matrix rather than just saying "fiber," which too many fail to properly appreciate.

A couple points I might challenge you on:

Although it might be counter-intuitive, I'd lump both the low-calorie density schemes and most versions of the "Mediterranean" diet (which has a somewhat elusive definition) under the same umbrella as "low-fat" diets. I know this sounds wrong because neither of those are inherently low-fat diets and perhaps that's my fault for dubbing the category that. I just mean that the experience a person goes through on either of those diets tends to mirror the low-fat experience where you might feel stuffed, but are generally less likely to feel satisfied. For me that was the reason I generally preferred the low-carb umbrella, since it would offer me an opportunity to feel satiety.

In the low-carb/keto world, I think part of properly appreciating that is throwing away the calorie concept and focusing more on avoiding "really good" foods that have more addiction-potential, if you will, while prioritizing foods that don't hijack your built-in hunger signaling. Obviously CICO is valid post facto, but you're going to lose the entire benefit of those diets if you're trying to engineer them to be low-calorie. As you noted previously, intentional low-calorie is generally going to be at odds with self-control, so to the extent you've rigged up a low-calorie version of Atkins, you're kind of throwing away the entire benefit of Atkin's: It's a diet where you can just eat until you're full (as long as you're selective about the foods you eat and stay within those bounds). It might not get you down to a 6-pack of abs before plateauing, but for most will get them to a better weight than they're currently at. Also, fun trivia fact for you. 100 years before Atkin's popularized his diet, a fellow by the name of William Banting popularized a rather similar diet that was dubbed the Banting diet at the time.

I'd also agree with you that the theories behind various low-carb concepts keep changing and will probably continue to keep changing. A very unique formulation of that concept, which isn't very popular, but I think is an interesting proof of concept is the ex150 diet. The guy is a blogger who likes to experiment with different diets and write about them. I wouldn't call him an expert, but he's very determined and also very diligent in recording very detailed data in what he does. The reason I think you might find it interesting is that the his main/default diet that he eats day to day is heavy cream (in addition to some beef and a small amount of vegetables). He eats it to satiety every day and has lost significant weight on it, after failing to find sustained success with other ketogenic diets. I don't find myself agreeing with a fair amount of his personal analysis, but that's not why I follow him. I just find his results to be very interesting.

 

[igottapee]

For good reason? GLPs help with the biological signals (crazy hunger or food noise) that can even make it hard to think. Hard to make permanent lifestyle changes when your body is in an alarmed/altered state. And everyone on GLPs has dieted and exercised before. I don't see GLPs as just a tool. But rather as a necessary, lifelong medication.

Yes, a healthier diet will help, as will exercise, and those things can help with bloodwork (as do GLPs), blood pressure (as do GLPs), and having a lower maintenance dose. And, of course, resistance training will help prevent losing muscle:

Agree. I think the pushback I was getting is that some think it's the "magic" pill, and won't get off the couch, death scrolling

 

[druell235]

Almost everyone on this forum has lost weight at some point in the past without GLP's. It is not super hard, you just have to decide to stick to a diet and stick to it and nearly everyone can do that for a while.

The problem with the "change you lifestyle" solution is not that it cannot work, but that it takes constant mental effort. Realistically if you were able to maintain that lifestyle/diet without a lot of constant mental work, you would not be obese. And eventually almost everyones' ability to put that effort in slowly wears away . If you succeed in establishing new habits that don't require that constant effort then you have solved the problem, but the reality of the research and most people's experiences says this is so hard that very few succeed. If your appetite regulation system cannot cope with constant cheap available high calorie highly rewarding food that it never evolved to deal with, then the only way not to eat too much is with constant effort and eventually that runs out.

Thankfully GLP's do not require constant effort for them to work, just injecting a medication once a week or so. Which bypasses that whole problem, and actually makes making and keeping to real meaningful long term lifestyle changes much easier and more likely. Simple example it is so much easier to exercise when not morbidly obese. So stopping them once at a goal weight actually puts those beneficial lifestyle changes as well as the weight loss at risk. I am not saying no one should ever try stopping them, but in severe longstanding obesity, I think it is a bad idea.

People vastly underestimate the mental effort it takes to maintain large weight loss. Your post reminds of something a fitness bro type influencer said on a random live I caught on TikTok a few months ago that has stuck with me. His audience was trying to get him to hate on people on GLP1's, and he said honestly IDGAF and good for them. He went on to say, yes people can white knuckle and use every ounce of mental effort they have to loose weight, but then they can't live the rest of their life. Using a GLP1 allows these people to live their lives and fix their bodies. It suck with me for being correct and because he was not someone who I thought would understand that.

 

[peppystrings80]

It's me! Hi! I'm the person with a long history of BED that often was better but never was well who Tirzepatide stopped cold and who has not had a binging episode or even had to struggle against a binging episode since, it's me.

Therapy didn't help. OA helped a very little. Nothing that didn't take every bit of concentration I had every day helped. Except the magic skinny shots, THEY fixed it and I'm all better now.

Right here with you! Me too! Not a single late night chocolate binge.

 

[RoadRash]

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.

Exactly. Read it the same way. Seems genuinely concerned for his patients.