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

[tubby]

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.

You're referring to a clinical trial result. That's insufficient to establish a standard of care. The relevant medical association will wait until they have multiple trial results (or whatever they consider to be sufficient evidence) before issuing guidelines. It's those guidelines that establish the standard of care.

I suspect they'll coincidentally get there once the majority of health plans provide temporary GLP coverage for obesity in some capacity. I mean you'd think the SURMOUNT trial would have been sufficient, but instead it will be whatever trial happens to reach completion at that point in time that will then add up to "just enough" for them to be ready to issue guidelines.

 

[DoctaDave]

I plan to never stop. These last 6 months have been a God send with not being constantly obsessed with food. My food noise was constant, and I always fought to not snack. I could eat a full meal, be completely satisfied and be ready to eat another full meal in 2 hours. Constantly hungry. Not anymore. Now I eat when I want and how much I want. Forget the weight loss (20% so far with hopefully another 50lbs to go) just the psychological rest with food has been worth it.

 

[Sasquatch]

It's interesting. I never was able to project/anticipate the long game. I have too much contempt for boards of people. I always thought the I.Q. of a board was the inverse of the collective/total.

 

[HereKittyKitty]

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.

To rx glp medication to a pt with a BMI of 15 would be egregious malpractice. Imvho.

Self-preservation is a thing, of course. Again, there's only so much I am comfortable to say in this setting.

I hear you.

 

[FarmgirlRebel]

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.

This for me as well. While not an alcoholic, I have a weird "tick" like ocd thing I do...but I no longer do while on Tirz. Holy cow, didn't even noticed I had stopped until my hubs said something to me ..there are indeed other benefits even over weightloss

 

[HereKittyKitty]

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).

I think of it in terms of the system actually recognizing obesity is a chronic disease with significant co-morbidities instead of viewing it - as they very often do - as an abject moral failure. If only obese people would eat less and move more.

At my heaviest, and in the hideous depths of medication-resitant depression and acute PTSD, a nurse practitioner said to me: just get outside and walk.

I could barely leave my house. I was almost completely non-functioning. I'd scheduled and canceled that appointment no less than 4 times before I actually kept it.

 

[Grogu]

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.

Nice article.

The only thing that surprised me was the statement above on patients who don’t respond or can’t tolerate any GLP-1 medication. I’m thinking that that number is probably much higher than 5%. Maybe the doc was just using 5% to say a smaller number.

The clinical studies have much higher rates of folks who discontinue. SURMOUNT-1 had 18% of participants not finish and the TRIUMP studies lost 20+% of study participants. Not all of these are related to side effects, but you’d think that the majority would be.

 

[Chili777]

Nice article.

The only thing that surprised me was the statement above on patients who don’t respond or can’t tolerate any GLP-1 medication. I’m thinking that that number is probably much higher than 5%. Maybe the doc was just using 5% to say a smaller number.

The clinical studies have much higher rates of folks who discontinue. SURMOUNT-1 had 18% of participants not finish and the TRIUMP studies lost 20+% of study participants. Not all of these are related to side effects, but you’d think that the majority would be.

I thought I read that 13% dropped out because they lost TOO MUCH weight? Might not have been that particular study. Such a 1st world problem.

 

[Wallydog]

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.

I was 6'1" 185 in HS and I didn't think I was a skinny kid. Played HS football etc but looking back at the pics from those days, many of us, me included, were kids not young men. Shoulders hadn't really broadened etc In that respect, the BMI stuff is complete shite. That's why I'm looking more at 220 for a TW .... if I upped my workout levels I might consider 210-215.

BTW - I'm a no ass guy too..

 

[Wallydog]

We don't need your glowing successes ruining our enjoyment of broccoli sandwiches, haha.

Do cream cheese and cucumber sandwiches! Yum.

That said, when I was in full weight loss mode on tirz, I ate what I called a Saladrito. The lazy male in me loves the ease of grabbing a fistful of salad mix and plunking it in a tortilla with a little hot sauce and feta cheese sprinkles. Roll it up and eat.

 

[Grogu]

I thought I read that 13% dropped out because they lost TOO MUCH weight? Might not have been that particular study. Such a 1st world problem.

Now that you say this, I recall that some of the dropouts in the Retatrutide studies were because the weight loss was “too fast”, not so much “too much” weight loss. But I still think that that was a small number as most stopped because of gastro side effects.

In the Semaglutide clinical studies the dropout rate varied but was generally in the 6-7% range for discontinuation due to adverse effects.

But yes, losing too much weight or losing weight too fast is definitely a 1st world problem. I wouldn’t be on that list for sure

 

[DunningKruger]

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.

I don’t believe GLPs cause eating disorders. What they do is act as an impetus: people who already had disordered tendencies (just on the overeating side) may get hooked on the dopamine rush of watching the scale go down. If the emotional and behavioural roots of the initial weight gain are ignored, they’re simply shifting from one form of disordered pattern to another.

 

[desinr-gal]

Do cream cheese and cucumber sandwiches! Yum.

That said, when I was in full weight loss mode on tirz, I ate what I called a Saladrito. The lazy male in me loves the ease of grabbing a fistful of salad mix and plunking it in a tortilla with a little hot sauce and feta cheese sprinkles. Roll it up and eat.

High cholesterol food is not going to improve her health. Healthy proteins would be better.

 

[lessthanhalf]

Binge eating disorder / food addiction is by a long way the most common eating disorder, being an issue for a fairly large percentage of obese people. There is a surprising lack of scientific studies of GLP's on this issue, but from what little there is , they are likely to be the most effective treatment available, and they help with obesity which is often the main problem for those with that sort of eating disorder. The only currently approved medical therapy is lisdexamphetamine, which is not very effective. Nearly every bit of research is from a psychology point of view, using cognitive behavioural therapy which is again not very effective for this problem. But given the research is mostly siloed in this area it might take a while for specific studies to be done with GLP's.

 

[Grogu]

I don’t believe GLPs cause eating disorders. What they do is act as an impetus: people who already had disordered tendencies (just on the overeating side) may get hooked on the dopamine rush of watching the scale go down. If the emotional and behavioural roots of the initial weight gain are ignored, they’re simply shifting from one form of disordered pattern to another.

While I agree that the glp-1 medications don't "cause" eating disorders, I definitely think that glp-1s can contribute to disordered eating especially for someone already vulnerable. Glp1s can reduce appetite so strongly that many people probably aren't eating enough calories or engage in behaviors around food that are problematic.

Binge eating disorder / food addiction is by a long way the most common eating disorder, being an issue for a fairly large percentage of obese people. There is a surprising lack of scientific studies of GLP's on this issue, but from what little there is , they are likely to be the most effective treatment available, and they help with obesity which is often the main problem for those with that sort of eating disorder. The only currently approved medical therapy is lisdexamphetamine, which is not very effective. Nearly every bit of research is from a psychology point of view, using cognitive behavioural therapy which is again not very effective for this problem. But given the research is mostly siloed in this area it might take a while for specific studies to be done with GLP's.

I'm fascinated with BED. Although I don't suffer with this disorder, I've read lots of posts of individuals with BED using glp-1 medications with good success even though glp-1s aren't FDA approved to treat BED. For most, I think that BED is primarily a psychiatric disorder involving loss of control, emotional triggers, and distress, rather than a metabolic condition. But if I had BED, I'd definitely be on a glp-1 whether I was obese or not.

 

[randompersonrandom]

I'm fascinated with BED. Although I don't suffer with this disorder, I've read lots of posts of individuals with BED using glp-1 medications with good success even though glp-1s aren't FDA approved to treat BED. For most, I think that BED is primarily a psychiatric disorder involving loss of control, emotional triggers, and distress, rather than a metabolic condition. But if I had BED, I'd definitely be on a glp-1 whether I was obese or not.

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.

 

[lessthanhalf]

A lot of my thinking on this issue is from my own experience. I do believe that at least in people with severe obesity the normal appetite regulation systems are really pretty broken.

I managed to get to 145kg and in some ways thankfully was stuck in a shitty situation, my business had died from covid, I had to sell my house, and was stuck living at my alcoholic ex's house for want of a better option. Classic lowest point to make real changes in your life.

So I used what I knew and started a diet, eating only low fat low glycaemic index generally low carb high protein low calorific density diet. The aim was to avoid spikes and dips in blood sugar or whatever regulating chemicals control appetite. At that point I believed glp's were impossibly expensive. And it worked, yes I was hungry all the time but not uncontrollably, and I got to 75kg in a bit less than a year. Importantly there had to be absolute zero high calorie high glycaemic index highly rewarding foods. In the past even small amounts of these foods had triggered uncontrollable extreme hunger that is much much more extreme after major weight loss. I think there is some pretty odd brain chemistry and physiology going on when this happens.

If binge eating disorder was primarily psychological, why would controlling the types of food I ate work so well to control it?

I kept the weight off for a year, still hungry a lot of the time but never uncontrollably , and finally realised glp's were an option. And they have made it much easier to keep the weight off , much less food required to feel full, less hunger overall and a lot less cravings for not allowed foods. But still sticking to absolute avoidance of certain foods.

 

[Ruckus4519]

I don’t believe GLPs cause eating disorders. What they do is act as an impetus: people who already had disordered tendencies (just on the overeating side) may get hooked on the dopamine rush of watching the scale go down. If the emotional and behavioural roots of the initial weight gain are ignored, they’re simply shifting from one form of disordered pattern to another.

One of the influencers on reta is somewhat mainstream now. I mostly know about reta from this forum, and maybe a little bit of reddit, but even my brother knows about the dude that uses meth for a better jawline.

Don’t know if that counts as an ED, or as orthorexia, but that’s definitely something .

 

[tubby]

A lot of my thinking on this issue is from my own experience. I do believe that at least in people with severe obesity the normal appetite regulation systems are really pretty broken.

I managed to get to 145kg and in some ways thankfully was stuck in a shitty situation, my business had died from covid, I had to sell my house, and was stuck living at my alcoholic ex's house for want of a better option. Classic lowest point to make real changes in your life.

So I used what I knew and started a diet, eating only low fat low glycaemic index generally low carb high protein low calorific density diet. The aim was to avoid spikes and dips in blood sugar or whatever regulating chemicals control appetite. At that point I believed glp's were impossibly expensive. And it worked, yes I was hungry all the time but not uncontrollably, and I got to 75kg in a bit less than a year. Importantly there had to be absolute zero high calorie high glycaemic index highly rewarding foods. In the past even small amounts of these foods had triggered uncontrollable extreme hunger that is much much more extreme after major weight loss. I think there is some pretty odd brain chemistry and physiology going on when this happens.

If binge eating disorder was primarily psychological, why would controlling the types of food I ate work so well to control it?

I kept the weight off for a year, still hungry a lot of the time but never uncontrollably , and finally realised glp's were an option. And they have made it much easier to keep the weight off , much less food required to feel full, less hunger overall and a lot less cravings for not allowed foods. But still sticking to absolute avoidance of certain foods.

Sounds somewhat similar to what I did after being diagnosed with diabetes to lose a bunch of weight and get it under control. In my case it wasn't low-fat, but we've all got our different opinions on what constitutes a "good" diet and I find it silly to argue over which dietary paradigm is the very best, other than to note that just about every single one is going to beat the Standard American (or in your case Australian) Diet.

I really do think that for a lot of people BED comes down to how well the most convenient food options in our environment have been engineered for their addictive potential. It's not so much that a person "has" it as that some people have better default defenses against that addiction potential than others and those with weak natural defenses will have to develop tricks to overcome it. In your example, you discovered that by changing what you were eating you greatly reduced the desire to binge, perhaps by choosing foods with less addiction potential. Even thought you were often hungry, that hunger wasn't enough to maintain the addiction, providing strong evidence that BED and being hungry can (at least for you) be two different things. And that kind of makes sense because the very nature of binging (eating way more food than required to make you full) keeps you eating until you feel like you're going to explode. If BED was just strong hunger, presumably the binges would catch you up to full rather than extreme overeating, and that's obviously not what it happening there.

 

[igottapee]

One of the influencers on reta is somewhat mainstream now. I mostly know about reta from this forum, and maybe a little bit of reddit, but even my brother knows about the dude that uses meth for a better jawline.

Don’t know if that counts as an ED, or as orthorexia, but that’s definitely something .

that would be clavicular. Supposedly he broke his jaw to get that jawline. They say meth, but I believe he uses adderall. He got popped/arrested a couple weeks back with a fake id and adderall w/o prescription