Hi everyone –
Should I take Ozempic? Does the weight come back? What exactly are GLP-1s?
I’m getting these questions a lot these days, from patients, from friends, and in DM’s from followers, so I decided to put my answers in one place and share them here. Also hi again – it’s been a minute since I last emailed. If you know anyone else that may want occasional updates about health topics of the day, have them sign up here.
Ozempic, Mounjaro and other GLP-1’s are in such high demand that pharmacies like Capsule can’t fill them. Direct-to-consumer sites like Calibrate, Found and Weight Watchers (which are all led by amazing female CEOs, btw) are effectively selling them for cash and health insurance company execs are wringing their hands at how much they’re spending to cover them. Word is the Blue Cross/Blue Shield network alone spent $1.8B in 2022, when these drugs were even less popular than they are today.
But wait, what exactly are GLP-1s?
GLP-1s, or Glucagon-Like Peptides, are hormones produced by the intestines that regulate appetite, food intake, intestinal mobility, and blood sugar levels. Medications based on GLP-1 are synthetic versions of these hormones, designed to elicit a stronger response. Originally developed to treat diabetes, their effect on weight loss was initially seen as a secondary benefit. However, with the introduction of newer drug versions and years of off-label use, these medications have surged in popularity. This rise is also supported by emerging research highlighting their diverse benefits.
We recently trained our entire clinical team on an updated GLP-1 protocol at Parsley, and I personally prescribed them twice in the past month — to a man dealing with obesity, a binge eating disorder, sleep apnea and who despite not being diabetic, qualifies for having a BMI > 30; and to an overweight but not quite obese woman who had been buying the drugs off the internet and taking them without medical supervision. Because she isn’t diabetic and her BMI isn’t quite high enough, she won’t qualify for insurance coverage, but our team would rather she have medical guidance and nutrition support while she’s on GLP-1s, given the risk of side effects.
But the biggest question posed to me isn’t how to get them covered or where to get them in stock. It’s do they actually work?
In my experience, the answer is: temporarily. GLP-1s have huge promise and I’m excited for their evolution but the jury is out on whether they are a sustainable solution.
They are highly effective for some people and the rapid weight loss that results includes both fat and muscle mass. Per the research, people lose on average 15-18% of their body weight over 68 weeks on the medication.
Because of the weight loss, patients benefit from lower blood sugar, improved blood sugar levels for diabetics and reduced instances of metabolic syndrome, resulting from lower food intake. Additional benefits include lower cholesterol and improved upregulation of certain pancreatic hormones and liver function. The side effects, like gastroparesis (stomach paralysis) and intestinal blockage, are serious but rare and can sometimes be avoided by increasing the dose in slower intervals and regular monitoring. As a physician, my concern is that the increased risk of metastatic melanoma may just be the tip of the iceberg on other unintended health consequences.
However, these drugs are marketed to individuals, as well as employers and health plans covering the expenses, as a ‘short-term kickstart.’ The aim is to assist people in gaining control over their weight while they adopt healthy dietary and exercise habits. These habits are intended to sustain weight loss and promote increased lean muscle mass and bone density.
Regarding this issue, I have not yet observed anyone who discontinued GLP-1 therapy without regaining weight, at least not so far. Some argue that we are still in the early stages of understanding these effects. Others contend that lifelong use of GLP-1s might be the only method for achieving sustainable weight loss. However, this could come at a significant cost, both financially and in terms of potential side effects. These side effects, which may include impacts on thyroid function or increased cancer risk, are not yet fully understood.
In my experience, when you essentially overnight mass prescribe a drug class that had been around but previously relegated to a narrow segment of the population, the medical community has come to anticipate that it’ll be 24-48 months until more of the wider risks and side effects become apparent (example: Ritalin).
So then why is Parsley prescribing them?
The reason is twofold: not only are GLP-1s a well-established class of diabetes medication that we were already prescribing, but Parsley Health is also dedicated to ensuring our providers are thoroughly trained and stay updated on the latest medications. This includes a comprehensive understanding of their risks, benefits, and side effects. We ensure these medications are prescribed appropriately and monitored safely, rather than risking our members self-managing the drug through consumer sites.
Our organization-wide protocol encompasses optimal nutrition and exercise recommendations to prevent weight regain and muscle mass reduction. We also focus on specific blood tests to monitor liver and pancreatic health while a patient is on these medications and provide guidance on safe titration. These are just a few examples. When our patients express interest or have questions, we strive to be a trusted source of perspective. This includes advising some patients against using the drug if it’s not appropriate or covered, based on their failure to meet certain criteria.
For the record, we are neither anti- nor pro-GLP-1; we adopt a personalized approach to clinical guidance for each patient. Along with the medical community, we remain cautiously optimistic that some patients will see long-term benefits from these medications.
The popularity of GLP-1s mask an underlying problem
In my opinion, the core issue is that Americans predominantly consume a diet of which 94% is refined or ultra refined sugars, flours, simple starches, and chemical additives like MSG. These components are designed to override our brain’s satiation signals, leading us to consume far more calories than needed. This situation is outwardly denied by the food industry, yet they continue to fund it. Certainly, obesity is a disease, not merely a ‘failure of willpower.’ However, when two-thirds of the U.S. population, including children, are overweight or obese and these numbers are soaring, it’s clear that environmental factors like diet and sedentary lifestyles are significant contributors to this modern illness.
I also believe our focus on weight, specifically the number on the scale, is misguided. True measures of metabolic health include balanced blood sugar levels (Hemoglobin A1C of 5.5 or less, fasting insulin below 10, and fasting blood sugar around 80), and a waist-to-hip ratio of less than 0.80 for women and 0.85 for men. This is because excessive abdominal fat is a key indicator of inflammation and mortality risk. If your scale weight is high, but you maintain an active lifestyle with a diet rich in whole foods, have strong lean muscle mass, a healthy waist-to-hip ratio, good blood sugar control, normal blood pressure, and high energy levels, then you’re on the right track. The scale’s reading becomes less significant.
For those on a GLP-1 regimen, maintaining lean muscle mass is achievable through weight training at least three times a week and consuming approximately 1 gram of protein per pound of body weight daily. More details on protein intake for muscle mass will be provided in a future post. If you’re using GLP-1 and aiming to discontinue it while keeping the weight off, retraining your palate to favor a whole-food, plant-dense diet that excludes packaged, processed, refined foods, added sugars, and alcohol, combined with exercises that enhance lean muscle mass, is your best approach.
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Product Recco:
Kosterina Olive Oil, founded by a Parsley member and one of our Parsley perks (i.e. you get a discount if you’re a patient). It’s pure EVOO (unlike most olive oils in the US that are cut with other oils even if they say olive oil on the packaging) and filled with amazing antioxidants, and monounsaturated fats that are heart-brain-gut healthy. You can basically drink it! And they have lovely gift sets for holiday.
Parsley News:
New York and California folks! We are in-network with all major health plans in the greater New York Area, and with Blue Shield California and Aetna California. This means your program fee is just $70 a month and that we bill your health plan for your doctor’s visits. Deductibles and copays apply. Get top notch care with doctors trained in root cause medicine, health coaching, and unlimited messaging with your care team between visits – so that you can get better and feel better.