"Is she on it?"
It used to be if you lost weight without announcing you were on a diet, the ghoul gossip was you might have cancer. Now they speculate you're on a GLP. Is everyone? A quick catch-up.
An octogenarian friend of mine swore me to secrecy last week before confiding she was taking Wegovy. “I couldn’t stand not being able to walk around anymore, always hurting. I begged my doctor to put me on it, and he finally did, and I’ve lost 17 pounds and I’m moving better already! But please … don’t tell anyone!”
Women are the top users of GLP-1s, and that made me wonder how many of us are out there: On a GLP, but embarrassed to admit it, feeling as if we were real women, we’d somehow be flagellating ourselves into thin-hood while still reveling in the fruits of those amber waves of grain.
Time for a GLP catch-up.
In the beginning
Believe it or not, it’s been 20 years since GLP-1s were first approved in the US. First was Byetta in 2005 for type 2 diabetes (T2D), followed by Victoza in 2010. During clinical trials and after release, researchers found that many patients taking the new drugs experienced significant weight loss—something Big Pharm had been working on for years. They were quick to jump on that use, and in 2014, the FDA approved Saxenda for weight loss.
Victoza and Saxenda were both injected daily, so the next big breakthrough, in 2017, was weekly injection Ozempic. The snowball started, and the rest is history we all know about today.
Why GLP-1s are a big deal
As this article from Harvard Health explains, “GLP-1 (glucagon-like peptide-1) receptor agonists is class of medications that work by mimicking the natural GLP-1 hormone. This hormone is released by the gut in response to eating and has several effects that help regulate blood sugar levels, hunger, and slow digestion.”
And that means it works on the foundation of so many diseases today. The Economist puts it well: GLP-1s are the “the Swiss Army knife of jabs.” Obesity and/or the same mechanism as obesity are at the foundation of so many diseases, it’s hard to list them all: cardiovascular health, kidney disease, arthritis, liver disease, brain health, addiction, some infertility, sleep apnea—the list goes on and on. Fix obesity, and many diseases improve quickly.
And that’s without even considering our addiction to the illusion of perpetual thinness.
Our post-WWII affluence, belief in “better living through chemistry,” Crisco foundations, and a taste for foods we now know may not have been all that good for us have come home to roost. Just in time, there might be a fix—although not without side effects,1 if you can tolerate them and the costs. Studies suggest up to 65% of those who start on GLP-1s don’t.
The most common positive comment among those on a GLP-1? “It quiets the food noise”—the voice saying you’re hungry. Where that noise comes from is what no one knows for sure yet, although there are increasingly hints. The most common complaints, according to 60,000 Facebook posts? GI issues (nausea, vomiting) for GLP-1s, and headache and joint pain with Mounjaro and Zepbound (tirzepatides).
Today it’s estimated that at least 1 out of 10 of us have used GLP-1s, and the predominant user is a woman age 50 to 64: this is very much a women’s health issue. Even more Americans with T2D—1 out of 4—used a GLP-1 last year. But with multiple ways of accessing the drugs or knock-offs, the true number who have at least tried a GLP-1 is likely much higher. The Information, a business publication, did an online survey of readers recently. Out of 900+ readers who completed the survey, 55% were either on an GLP-1 or had used one previously.
The usage forecast is even more startling: One forecaster predicts a market value of $63B this year, set to grow at 17.5% CAGR through the next ten years.
And that’s with a US list cost of $1000 or more per month, although Novo Nordisk just announced they’re cutting the price of Ozempic in half. Imagine what the forecast would be here if we paid the list price of $83 to $170/month in other countries—although the drug companies are undoubtedly imagining just that now that the major plundering has played out a bit and we’re definitely hooked.
GLP-1s are also reshaping the economy, from grocery costs to restaurant offerings. We’ve never had a drug with so many major economic downstream effects, and we’re just starting to see the entire picture.
What does going on a GLP-1 look like?
Let’s switch to two Substack authors for a look at that.
Dr. Laurie Marbas, unquestionably the queen of habit-breaking, has a great post on Should you take a GLP-1? The real story behind the weight loss shots. It’s a great primer on what the drugs are, why so many people are taking them, side effects, and how we can wire our bodies to produce more of the same hormones naturally. Importantly, she stresses that if we aren’t ready to do the work, we shouldn’t take them2 and ends the post with her trademark Habit Healer approach.
Dr. Mary Braun Bates does her usual terrific job taking us through the decision-making process in Help me unpack my weight, Doctor. Dr. Bates uses amalgams—personas—of patients she’s seen and known in the office to explore the decision-making process, with pros and cons unveiled along the way. We get to see both how patients come to, and react in, the office (shades of ourselves), as well as the physician’s thought process. It’s a great way to follow along and consider what your own responses would be, look at the potential benefits, and also see how our minds minimize the costs and the work involved—and can cling to visions of somehow becoming a 20-year-old beauty queen.
How much could we lose? Is it a lifetime commitment?
How much could we expect to lose? So far, from a scientific analysis, we don’t have an “average” because so many people are taking it from so many sources for so many reasons. It depends on goals, where we start, and what we put into it. Manufacturers promise only “modest” weight loss. And while studies show 12% weight loss, everyone knows people who have lost far more than that — or far less.
Forbes Health’s 2025 ranking of best places to obtain weight loss drugs.
There’s a vast difference between losing 10 pounds in time for a wedding versus someone weighing 300 pounds intent on getting healthy forever—she could lost 60 pounds in a year. And yes, in serious weight loss and T2D, GLP-1s are considered to be a lifetime commitment; for now, going off clearly means rebounding.
On the other hand, we’re really, really new at this. New approaches will build off the science we now have; we’re learning a huge amount with these drugs. It’s naive not to expect even better options in the future.
GLP-1s in the news
Kennedy’s FDA is tightening controls on cheaper, non-FDA-approved GLP-1s. Unfortunately, at this point in Kennedy’s FDA, it’s hard to know whose side they’re on, as boxing out the compounding pharmacies who produced millions of doses to support Big Pharma’s slow manufacturing will now primarily benefit Big Pharma.
With so many on high cost GLP-1s, off-label microdosing—taking less than the prescribed amount of the drug—was bound to show up. Microdosing, is not yet supported by standard research clinical trials. As a result, information on microdosing will largely be from individual doctors and/or weight loss practices or spas—not Big Pharma (so far) or the government—and those physicians say microdosing is simply adjusting dosage to patient needs. GLP-1 providers and users consider microdosing to reduce side effects, manage costs, achieve more gradual weight loss or to maintain weight loss when goal is reached.
Although off-label, GLP-1s are being used in management of T1D in children and adaults … not to replace insulin, but to help the body’s other hormones do their jobs better. Read more here.
Insurers are wavering on coverage, particularly when the use is for weight loss, not T2D. While they mutter about “costs, long-term safety and effectiveness, and coverage not required under the ACA,” when you get down to it, it’s pretty simple. Our for-profit insurance companies have to generate a ROI to investors. Increasing numbers of people using GLP-1s increase insurer costs, reducing profits. Profits are reported quarterly, and if GLP-1s improve someone’s health—meaning lower care costs later in life—it doesn’t matter for this quarter’s report … yet another way we’re hurting ourselves with our for-profit healthcare system, unlike the public/non-profit coverage mixes in our peer countries.3
That’s another incentive, though, for manufacturers to decrease costs—along with pressure from people like Bernie Sanders, who keep asking why GLPs cost so much more in the US. The latest cost-cut from NovoNordisk was made after Trump’s EO on drug costs, although NovoNordisk is also keen to address competition from cheaper compounded versions.
Learn more
BrightFocus: How GLP-1s could transform Alzheimer’s treatment.
Medscape: WHO adds GLP-1s to list of “essential medicines” for T2D, although not yet for obesity.
Nature Reviews—Endocrinology: Balancing weight and muscle loss ins GLP-1 therapy.
NPR: I quit Ozempic and embraced feeling healthy over striving for thinness.
OpenAccessGovernment: What makes GLP1 drugs so effective for obesity?
Science Direct: The expanding benefits of GLP-1 medicines.
Nature Medicine: Ultraprocessed or minimally processed diets following healthy dietary guidelines on weight and cardiometabolic health: a randomized, crossover trial. (Translation from NYT: Avoiding UPFs might double weight loss)
If you have a lot of weight to lose, you may or may not want to read about this particular side effect.
Don’t underestimate that: I’ve talked to people who were on Victoza or another GLP-1 for months—even several years—and never lost more than a few pounds … until they got serious about weight loss. Once they did the work (nutrition tracking and exercise), several of them lost 60 or more pounds over a year. Along those lines, here’s a review of nutrition and exercise tracking apps.
50 pounds down and now looking for real guidance on maintenance- micro-dosing is likely in my future. I’m not shy about telling about my Wegovy experience - or any of the other (MANY) ways I’ve tried to get back to a weight that would pass as normal. Weight loss has ceased to be a psychological burden, just a financial one. And now that I’m at goal, there is no chance I’ll ever get insurance coverage, and I’m never going back. So I’ll figure it out. 🤷♀️
There’s something so telling in that whispered “don’t tell anyone.” It says more about our culture’s gaze on women’s bodies than it does about the medicine itself.