What To Consider When Considering a GLP-1 How I Actually Think About It with Patients
Recently, one question that comes up a lot from new patients is whether or not a GLP-1 is right for them. Some have decided already and want me to write the prescription. Others have decided against it and want me to confirm that the medication is not for them. Most are not sure, and for all of these women, a conversation with a doctor who really understands the nuances of GLP-1s and their prescribing is a good place to start.
Have similar questions? Let’s get into it.
The Medical Starting Point
The most common GLP-1 receptor agonists you may have heard of are semaglutide, sold as Wegovy and Ozempic, and tirzepatide, sold as Zepbound and Mounjaro. New versions include oral semaglutide, sold as oral Wegovy, and an oral non-peptide GLP-1, orforglipron, sold as Foundayo. The labeled indications for the weight-management versions are a BMI of 30 or above, or overweight with at least one weight-related condition.
The list of conditions that are considered weight-related includes:
Hypertension
Dyslipidemia
Type 2 diabetes
Obstructive sleep apnea
Fatty liver disease
Established cardiovascular disease like heart attack or stroke
The label says “such as” when listing weight-related conditions, which implies the list is not exhaustive. In practice, qualifying conditions, though not necessarily approved by insurance, also include:
Prediabetes
Metabolic dysfunction-associated steatohepatitis (also called MASH)
Knee or hip arthritis
GERD
Chronic kidney disease
Some of the injectable GLP-1s also have FDA indications for specific conditions: Wegovy for fatty liver and cardiovascular disease, and Zepbound for moderate-to-severe sleep apnea.
As you can see, there are a lot of conditions. PCOS is one where I think it is worth having a discussion about whether a GLP-1 is a good option, and the 2023 International PCOS Guideline conditionally recommends GLP-1 receptor agonists for weight management in adults with PCOS. Other indications I have been watching are for autoimmune diseases like psoriatic arthritis or rheumatoid arthritis, and for substance use disorders.
A Question I Ask Before the Prescription
Often when I talk to someone about starting a GLP-1, I ask them what their goals are and why they want it.
Sometimes the answer is that they want to lose weight, because they don’t like the way they look, or because they feel uncomfortable in their body.
The voice that judges a body tends to keep judging. I have watched patients reach a weight they had been working toward for years and find the judgy voice still there with new material.
This is not a reason against starting the medication. It is a reason to add additional support, like a therapist who works on body image.
If the only thing standing between you and a healthy relationship with your body is the number on the scale, then unfortunately the GLP-1 is not going to get you to that goal. Quieting that judgmental voice in your head is its own work, and it requires its own support. It is something that needs to happen alongside the GLP-1 if that ends up being the right medication for you.
It can also be helpful to have a dietitian who does not use words or tactics like shaming to help you reach your goal.
The version of this that tends to go badly is the one where the medication is carrying all of the hope of finally feeling okay in your body, with nothing else supporting it. That almost always ends in disappointment.
When Your Values and Your Diagnosis Are Not in the Same Place
There is another version of this conversation, where a patient has done all the work of learning to love and accept her body, and show love and respect to her body, even when it does not conform to societal norms.
For new reasons, choosing intentional weight loss may align more with her health goals than it did before. She may have a new diagnosis of diabetes, prediabetes, or fatty liver disease, and want to make adjustments so that the complication is resolved. Or she may suddenly find that her knee pain from osteoarthritis is significant enough that she would like a knee replacement, and in order to get that knee replacement, her BMI has to be at a certain number for the surgeon to proceed.
These patients are harder, but also the ones where a physician who understands the complexity of food behavior, body image, and diet culture is a great person to have on your team.
Both things can be true. Your body is good. It has carried you through this life and deserves respect. And it may also be asking for support right now that does not fit cleanly inside the framework you have built. Sitting with that, rather than rushing to resolve it in either direction, is part of the work.
Does that mean every woman in a larger body with a metabolic diagnosis or osteoarthritis of the knee should choose intentional weight loss? No. There are other tools, and there are real reasons a patient might decide that intentional weight loss is not the path she wants to take, even when evidence supports it as one of the options.
GLP-1s are also not the only way to improve a fatty liver or move a hemoglobin A1C in the right direction. But it would not be an honest, fully informed conversation if intentional weight loss were left out of the discussion entirely. For some metabolic conditions, weight change is part of how the disease improves. That is what the evidence says, and I would not be doing my job if I edited it out because the feelings around medication and weight loss are uncomfortable.
What I tell my patients in that position is that medical care should always align with your values. My job is to give you a clear picture of what each option does, what it costs, what it asks of you, and what the evidence actually shows. The choice is yours, made with all of the information, and not pre-decided by me or by an algorithm or by the loudest voices on either side of the internet.
If You Are Starting a GLP-1
A colleague of mine, Dr. Sarah Stombaugh, has put together a thorough GLP-1 start guide that covers what to expect on the medication, how it works, common side effects, and how to think about dosing and titration. I send patients to it often.
Dr. Sarah Stombaugh’s GLP-1 Start Guide (affiliate link)
A quick note: I do receive a small commission if you purchase through that link, which I am telling you because I think you should know.
If You Want to Talk It Through
If you would like to talk about your own version of this question with a doctor who has time for it, the discovery call is fifteen minutes, no charge, and no pressure to do anything afterward. We can talk through whether becoming a patient at Sorrel Health and Wellness is right for you.
