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

[Calm Logic]

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



Some GLP-1 patients are begging to stay on the drugs just a little bit longer, presenting an ethical dilemma for doctors.

www.statnews.com

We’ve gone from weight loss drug shortages to a problem of excess — and eating disorders​#-weve-gone-from-weight-loss-drug-shortages-to-a-problem-of-excess-and-eating-disordersBy Jody Dushay, MD

Feb. 19, 2026

...From what I have seen in practice, those on GLP-1 therapies can be grouped into a few distinct groups.

For most — the average responders — body weight drops by 10% to 20% across six to 12 months, and with continued treatment, the bulk of that loss is maintained.

Roughly 5% either cannot tolerate any GLP-1 medication or show no response at all: their weight loss is minimal or absent, or side effects force them to quit.

A further approximately 5% of my patients are super responders, shedding over 25% of their body weight. I have witnessed figures as high as 45%. Genetics probably play at least some role in why certain people fail to respond — or respond excessively — to pharmacologic levels of GLP-1. As of now, no straightforward blood test exists that can forecast how strongly someone will respond.

Sooner or later, at the maximum tolerated GLP-1 dose, every person hits a weight loss plateau. And hardly anyone has told me that the weight at which they plateau is their Goldilocks weight. It happens often that people grow so focused on a particular scale reading that they overlook the enormous gains they have made in overall health. Nearly all of them want to lose more, and I am figuring out in real time how best to support patients whose plateau weight is above what they had envisioned when starting treatment. It feels to me like telling someone who trained for a marathon to be content after 10 kilometers.

What I find hardest, though, is helping people grasp why I believe they have shed too much weight, and why in certain cases I put my foot down about stopping or sharply reducing their GLP-1 dose. The negotiation becomes really tough when someone suggests, “How about if I just stay on the same dose for another few months, in case I gain weight on vacation/after menopause/over the holidays?”

As an endocrinologist, treating eating disorders or disordered eating is not part of my professional training, yet I recognize both when they appear, and sadly I am seeing them with growing frequency.

For individuals dealing with intrusive cravings, relentless food thoughts, and a dulled sense of fullness, GLP-1 therapies are unquestionably transformative. That said, a total absence of appetite is abnormal and goes beyond what GLP therapies ought to produce. The same holds for fear of food and fixation on a particular weight. Red flags include stress at home around mealtimes, friendships strained because social gatherings involving food feel uncomfortable, or a partner, child, or parent believing someone has developed highly abnormal eating habits.

Because they don’t want to reduce their dose or quit the medication, some of my patients downplay GLP-1 side effects — a choice that can result in serious complications. I do not routinely track longitudinal changes in body composition or bone mass among people on GLP-1s, largely because DXA scans are costly, but substantial muscle or bone loss are two objective signs of excessive weight loss that ought to prompt stopping or slowing treatment.

To be sure, I respect that weight loss is a struggle for these patients, and I prescribe and advocate for medication to help people lose weight.

But I am also responsible when a physical or mental health threshold has been crossed. We live in a society where weight is seen as a readout of health, which is as inaccurate as it is unfortunate. Weight and BMI are only one metric of physical and emotional health. Just as important are what a person puts into and does with their body at any weight. The cutoffs for healthy weight based on body mass index (BMI) are plagued by the shortcomings of BMI itself, which should not be used as the only determinant of complicated obesity.

So how do I decide in the moment if a person in front of me is at a healthy weight? I use a collection of objective measurements such as cholesterol levels, blood pressure, waist size, blood sugar, and liver function to support my clinical judgement. I also ask patients what they eat over the course of a typical day, how much physical activity they get, and if they have enough energy to do things they enjoy...

When treatment begins, I aim to learn why someone wants to lose weight, and I steer clear of assigning a numeric weight loss target. Excessive weight loss is real, and my hope is that it will not become something I encounter more frequently as a consequence of GLP-1 therapies.

 

[Nmcoyote1]

I wish I were among the 45% super responders. My loss came to 34%, yet by BMI I remain overweight. At 5’6”, my current weight is 215. Back in 2008, when I dropped 40 pounds and reached 180, my wife felt I appeared too thin. That’s why I set 190 as my target. Since roughly may 2025, progress has stalled. Right now I’m stacking 1mg Sema with 5mg Reta, hoping the scale will start moving downward once more. It seems to be working slowly.

 

[lessthanhalf]

I realize this piece came from a practising endocrinologist who is grappling with these questions in the clinic, and who has very little research evidence to lean on when deciding what should happen once weight has already come off on these drugs.

My reading is that his views are shaped heavily by older ideas about what weight loss was achievable and safe, back when keeping off 5-10% counted as a great outcome for health.

That picture no longer holds. Far better results are now within reach — not for everybody, since some people either can't handle the drugs or don't respond well — but for many, a 20% reduction is entirely attainable. What keeps striking me is how rarely I encounter people on this forum who are stalled midway to their target after shedding roughly 20%, when the trial data suggest that should describe nearly all of the more severely overweight. Even allowing for a self-selected group, plus peptide stacking and several GLP's together, it ought to turn up more often than it does.

There is a legitimate role for the worried, paternalistic tone he adopts: using these drugs without medical oversight or guidance brings added dangers, quite apart from any risk from tainted, mislabelled or counterfeit products. Dosing mistakes made through the DIY route do land people in hospital fairly regularly. Still, that outlook sits fundamentally at odds with a patient's or a person's right to make their own medical choices, and medicine has never been good at handling that tension. Obviously giving GLP's to someone with anorexia nervosa is a bad idea, but I would place the boundary between patient autonomy and paternalism much nearer the autonomy end than he does.

The long-term health evidence in people who are severely obese, diabetic, or living with heart disease is unmistakable: these drugs markedly improve health, and solid research shows the advantage grows at higher therapeutic doses rather than lower ones. That undermines the medical rationale for halting or cutting doses in some of his patients, since the evidence is equally plain that ceasing these drugs or lowering the dose brings weight back, along with the health harms that follow.

As for judging treatment by his own read of its effect on quality of life — once again, the person themselves is normally best placed to make that call, with a handful of exceptions such as serious eating disorders.

From what I've seen, most doctors carry the same prejudices toward people with severe obesity as everyone else. This doctor doesn't appear to display that, yet it's highly unlikely he grasps anything close to the full lived reality of being in that state. Severe obesity brings severe social penalties — lower income, being regarded as less than human by strangers — and those pressures, more than the health ones, are what push people to want to shed weight. With milder obesity the penalties are smaller but still far from trivial.

I believe he is missing the larger picture of his patients' lives, and that this is what tilts him toward excessive caution with these medications.

Before GLP's existed, only an astonishingly tiny slice of the population ever managed major long-term weight loss, and the rare few who did had to overhaul their lives and control food and exercise obsessively. Yet he opts to withdraw medication when it disrupts the social side of eating. Sustaining a large loss over years demands fairly obsessive control over what you eat; when nearly everyone around you eats poorly, declining the same foods will always create friction around shared meals.

I doubt I'd stay his patient for long. Having lost 54% of my weight and living on a very narrow, repetitive diet sounds a great deal like his warning signs, yet that is precisely what holding onto such a loss requires (along with some reta and 15mg of tirzepatide).

Because far cheaper pirate Chinese GLP's are so readily obtainable, his stance could drive the very people he thinks should be on lower doses or off treatment — those who reject his judgment — into the grey market.

Watching how this market has expanded over the past year or so, it will grow vastly larger ahead. The bottled-up demand from literally billions of obese people who would rather weigh less is immense, and on top of them are all those who are somewhat overweight and would rather be slimmer for fairly sensible social reasons (society judges fat people, and harshly). Legitimate versions cost so much that a black market was unavoidable, and while I expect prices to moderate in a few years as competition builds, this kind of over-paternalistic medical posture drives people away from the medical route and toward the grey or black market. That does bring added risks, chiefly from other related medical problems going untreated — optimal management of blood lipids, diabetes and pre-diabetes, and hypertension — as well as from exposure to, and possible use of, an entirely different set of peptides that for the most part have no human trials showing they work or are safe.

 

[Candaril]

I get both sides here — what it’s like for the patient and what it’s like for the doctor.

Mounjaro took 30% off my weight in a year, and these days I’m in maintenance.

Logically, I ought to be stepping the dose down little by little so I don’t keep shedding pounds while eating as I normally do.

Instead, I’ve been adding more calorie-dense foods to stop any more weight loss, and that’s how I’m holding steady.

Reducing the dose is just something I can’t make myself do.

Probably psychological, I think.

 

[HereKittyKitty]

lessthanhalf said:

I realize this piece came from a practising endocrinologist who is grappling with these questions in the clinic, and who has very little research evidence to lean on when deciding what should happen once weight has already come off on these drugs.

My reading is that his views are shaped heavily by older ideas about what weight loss was achievable and safe, back when keeping off 5-10% counted as a great outcome for health.

That picture no longer holds. Far better results are now within reach — not for everybody, since some people either can't handle the drugs or don't respond well — but for many, a 20% reduction is entirely attainable. What keeps striking me is how rarely I encounter people on this forum who are stalled midway to their target after shedding roughly 20%, when the trial data suggest that should describe nearly all of the more severely overweight. Even allowing for a self-selected group, plus peptide stacking and several GLP's together, it ought to turn up more often than it does.

There is a legitimate role for the worried, paternalistic tone he adopts: using these drugs without medical oversight or guidance brings added dangers, quite apart from any risk from tainted, mislabelled or counterfeit products. Dosing mistakes made through the DIY route do land people in hospital fairly regularly. Still, that outlook sits fundamentally at odds with a patient's or a person's right to make their own medical choices, and medicine has never been good at handling that tension. Obviously giving GLP's to someone with anorexia nervosa is a bad idea, but I would place the boundary between patient autonomy and paternalism much nearer the autonomy end than he does.

The long-term health evidence in people who are severely obese, diabetic, or living with heart disease is unmistakable: these drugs markedly improve health, and solid research shows the advantage grows at higher therapeutic doses rather than lower ones. That undermines the medical rationale for halting or cutting doses in some of his patients, since the evidence is equally plain that ceasing these drugs or lowering the dose brings weight back, along with the health harms that follow.

As for judging treatment by his own read of its effect on quality of life — once again, the person themselves is normally best placed to make that call, with a handful of exceptions such as serious eating disorders.

From what I've seen, most doctors carry the same prejudices toward people with severe obesity as everyone else. This doctor doesn't appear to display that, yet it's highly unlikely he grasps anything close to the full lived reality of being in that state. Severe obesity brings severe social penalties — lower income, being regarded as less than human by strangers — and those pressures, more than the health ones, are what push people to want to shed weight. With milder obesity the penalties are smaller but still far from trivial.

I believe he is missing the larger picture of his patients' lives, and that this is what tilts him toward excessive caution with these medications.

Before GLP's existed, only an astonishingly tiny slice of the population ever managed major long-term weight loss, and the rare few who did had to overhaul their lives and control food and exercise obsessively. Yet he opts to withdraw medication when it disrupts the social side of eating. Sustaining a large loss over years demands fairly obsessive control over what you eat; when nearly everyone around you eats poorly, declining the same foods will always create friction around shared meals.

I doubt I'd stay his patient for long. Having lost 54% of my weight and living on a very narrow, repetitive diet sounds a great deal like his warning signs, yet that is precisely what holding onto such a loss requires (along with some reta and 15mg of tirzepatide).

Because far cheaper pirate Chinese GLP's are so readily obtainable, his stance could drive the very people he thinks should be on lower doses or off treatment — those who reject his judgment — into the grey market.

Watching how this market has expanded over the past year or so, it will grow vastly larger ahead. The bottled-up demand from literally billions of obese people who would rather weigh less is immense, and on top of them are all those who are somewhat overweight and would rather be slimmer for fairly sensible social reasons (society judges fat people, and harshly). Legitimate versions cost so much that a black market was unavoidable, and while I expect prices to moderate in a few years as competition builds, this kind of over-paternalistic medical posture drives people away from the medical route and toward the grey or black market. That does bring added risks, chiefly from other related medical problems going untreated — optimal management of blood lipids, diabetes and pre-diabetes, and hypertension — as well as from exposure to, and possible use of, an entirely different set of peptides that for the most part have no human trials showing they work or are safe.

I get where you're coming from, and I can see the logic behind your point. What's interesting to me is that the article doesn't strike me as paternalistic at all. Instead, my reading is of a doctor who takes the Hippocratic Oath seriously — the oath that binds physicians ethically. What I see is tension: on one side, backing these medications, maybe even actively promoting them, given the remarkable success rates they can produce; on the other, the wide range of outcomes that come with them. Body dysmorphia isn't a myth. Disordered eating isn't a myth either.

For many people, the idea of ever living without obesity was pure fantasy. Now they're going through physical transformations in ways that would have been impossible to picture before. And once someone finds something that works this well, crossing the line into overuse isn't much of a stretch.

I don't know this physician personally, so his motives, his manner with patients, and his overall philosophy are all unknown to me. But I do know this much: it's entirely plausible that he genuinely worries about what his patients are up against, and that he wants to find a way to keep supporting their health as an ethical medical professional.

There's a great deal more I'd like to say, but saying it would expose too much about me in a space where I'd rather stay anonymous than be identifiable. And no — I'm not a physician.

 

[byefatlicia]

The eating disorder angle is a hard one to untangle. Whether the GLP's are actually triggering some eating disorders, or simply being used as a tool by people who already have one, I can't say for certain.

For years, over-eating was slowly killing me. Food was my drug. Yet under-eating can be just as deadly.

Still, the same freedom that lets someone over-eat also lets someone under-eat.

I get why a Doc wouldn't want to be part of pushing anyone toward either extreme.

But here in the Grey, nobody can block the "prescription". In the same way, back when food was my addiction, nobody could have blocked me from buying and eating.

 

[tubby]

MeedzMoar said:

lessthanhalf said:

I realize this piece came from a practising endocrinologist who is grappling with these questions in the clinic, and who has very little research evidence to lean on when deciding what should happen once weight has already come off on these drugs.

My reading is that his views are shaped heavily by older ideas about what weight loss was achievable and safe, back when keeping off 5-10% counted as a great outcome for health.

That picture no longer holds. Far better results are now within reach — not for everybody, since some people either can't handle the drugs or don't respond well — but for many, a 20% reduction is entirely attainable. What keeps striking me is how rarely I encounter people on this forum who are stalled midway to their target after shedding roughly 20%, when the trial data suggest that should describe nearly all of the more severely overweight. Even allowing for a self-selected group, plus peptide stacking and several GLP's together, it ought to turn up more often than it does.

There is a legitimate role for the worried, paternalistic tone he adopts: using these drugs without medical oversight or guidance brings added dangers, quite apart from any risk from tainted, mislabelled or counterfeit products. Dosing mistakes made through the DIY route do land people in hospital fairly regularly. Still, that outlook sits fundamentally at odds with a patient's or a person's right to make their own medical choices, and medicine has never been good at handling that tension. Obviously giving GLP's to someone with anorexia nervosa is a bad idea, but I would place the boundary between patient autonomy and paternalism much nearer the autonomy end than he does.

The long-term health evidence in people who are severely obese, diabetic, or living with heart disease is unmistakable: these drugs markedly improve health, and solid research shows the advantage grows at higher therapeutic doses rather than lower ones. That undermines the medical rationale for halting or cutting doses in some of his patients, since the evidence is equally plain that ceasing these drugs or lowering the dose brings weight back, along with the health harms that follow.

As for judging treatment by his own read of its effect on quality of life — once again, the person themselves is normally best placed to make that call, with a handful of exceptions such as serious eating disorders.

From what I've seen, most doctors carry the same prejudices toward people with severe obesity as everyone else. This doctor doesn't appear to display that, yet it's highly unlikely he grasps anything close to the full lived reality of being in that state. Severe obesity brings severe social penalties — lower income, being regarded as less than human by strangers — and those pressures, more than the health ones, are what push people to want to shed weight. With milder obesity the penalties are smaller but still far from trivial.

I believe he is missing the larger picture of his patients' lives, and that this is what tilts him toward excessive caution with these medications.

Before GLP's existed, only an astonishingly tiny slice of the population ever managed major long-term weight loss, and the rare few who did had to overhaul their lives and control food and exercise obsessively. Yet he opts to withdraw medication when it disrupts the social side of eating. Sustaining a large loss over years demands fairly obsessive control over what you eat; when nearly everyone around you eats poorly, declining the same foods will always create friction around shared meals.

I doubt I'd stay his patient for long. Having lost 54% of my weight and living on a very narrow, repetitive diet sounds a great deal like his warning signs, yet that is precisely what holding onto such a loss requires (along with some reta and 15mg of tirzepatide).

Because far cheaper pirate Chinese GLP's are so readily obtainable, his stance could drive the very people he thinks should be on lower doses or off treatment — those who reject his judgment — into the grey market.

Watching how this market has expanded over the past year or so, it will grow vastly larger ahead. The bottled-up demand from literally billions of obese people who would rather weigh less is immense, and on top of them are all those who are somewhat overweight and would rather be slimmer for fairly sensible social reasons (society judges fat people, and harshly). Legitimate versions cost so much that a black market was unavoidable, and while I expect prices to moderate in a few years as competition builds, this kind of over-paternalistic medical posture drives people away from the medical route and toward the grey or black market. That does bring added risks, chiefly from other related medical problems going untreated — optimal management of blood lipids, diabetes and pre-diabetes, and hypertension — as well as from exposure to, and possible use of, an entirely different set of peptides that for the most part have no human trials showing they work or are safe.

I get where you're coming from, and I can see the logic behind your point. What's interesting to me is that the article doesn't strike me as paternalistic at all. Instead, my reading is of a doctor who takes the Hippocratic Oath seriously — the oath that binds physicians ethically. What I see is tension: on one side, backing these medications, maybe even actively promoting them, given the remarkable success rates they can produce; on the other, the wide range of outcomes that come with them. Body dysmorphia isn't a myth. Disordered eating isn't a myth either.

For many people, the idea of ever living without obesity was pure fantasy. Now they're going through physical transformations in ways that would have been impossible to picture before. And once someone finds something that works this well, crossing the line into overuse isn't much of a stretch.

I don't know this physician personally, so his motives, his manner with patients, and his overall philosophy are all unknown to me. But I do know this much: it's entirely plausible that he genuinely worries about what his patients are up against, and that he wants to find a way to keep supporting their health as an ethical medical professional.

There's a great deal more I'd like to say, but saying it would expose too much about me in a space where I'd rather stay anonymous than be identifiable. And no — I'm not a physician.

At first, after I read it, I shared both of the reactions you two had. But the more I sat with it, the more it seemed to me that this endocrinologist — who I’m assuming sees patients in the US — is probably speaking in code, and may not even see how that code is tilting the stance he takes:

Sure, he carries a malpractice policy. Even so, his first instinct is going to be shielding himself and his practice from any possible legal exposure. He’d never say so out loud, but when optimal care and that protection pull in different directions, protection wins. Take an extreme scenario: someone with a BMI of 15 walks in and insists on a bigger GLP dose. If he said yes, it’s not hard to imagine him later having to justify that choice in court, should something happen that could be painted as a consequence of that prescribing decision.

And yet, when a doctor is face to face with a patient, you’ll almost never hear “I’d like to give you what you’re asking for, but you might sue me down the line, so I won’t.” What comes out instead is language that frames the refusal as his own clinical call — and after enough years, he may genuinely start believing that’s what drives it. Once that habit sets in, he’ll keep reaching for the same kind of phrasing whenever he explains limits, to the point that an article like this one ends up using a framing that’s both absurd and needlessly provocative, because it suits the persona better than owning up to the simpler motive: not wanting to be sued if he can avoid it.

 

[randompersonrandom]

It’s odd that they frame it as "stopping," as though that wouldn’t just lead to regaining the weight, which we basically KNOW will happen. Reducing the dose, fine, but quitting entirely? What for—so you can repeat the whole thing 12 months from now?

 

[Zydeceltico]

Nmcoyote1 said:

I wish I were among the 45% super responders. My loss came to 34%, yet by BMI I remain overweight. At 5’6”, my current weight is 215. Back in 2008, when I dropped 40 pounds and reached 180, my wife felt I appeared too thin. That’s why I set 190 as my target. Since roughly may 2025, progress has stalled. Right now I’m stacking 1mg Sema with 5mg Reta, hoping the scale will start moving downward once more. It seems to be working slowly.

I'm in a fairly similar bind — I hit my goal weight and started looking "too thin" while my BMI was still in "overweight" territory rather than the healthy range. At 5'-11" I'm now 185 lbs, and by BMI I'm still a few pounds into "overweight." Since cardiovascular risk is what I care about most, seeing that BMI number makes me uneasy; at the same time, my girlfriend tells me I'm getting far too skinny. When I check the mirror, I have to admit she has a point.

SOOOOOOOO........ rather than BMI, I've switched to a different, newer way of judging my overall weight health: Waist/Hip Ratio (WHR - look it up). For men, WHR ought to be around .90. Mine is .98. The thing is, I was never genetically blessed with much of a butt, so instead of trying to trim my waist further, I'm working on making my butt bigger — which translates to a LOT of heavy hip thrusts at the gym. LOL - and it's starting to show results. My butt gained 1/4" over the last 2 months. My waist is unchanged.

 

[Sasquatch]

randompersonrandom said:

It’s odd that they frame it as "stopping," as though that wouldn’t just lead to regaining the weight, which we basically KNOW will happen. Reducing the dose, fine, but quitting entirely? What for—so you can repeat the whole thing 12 months from now?

Does this group—those of us here on this forum—even register as real to doctors who are licensed and practicing? We hold a mountain of information since we guide ourselves. Yet I doubt a single physician could show up here, within the rules of their license, just to pick up what we, this community, have learned.

 

[tubby]

randompersonrandom said:

It’s odd that they frame it as "stopping," as though that wouldn’t just lead to regaining the weight, which we basically KNOW will happen. Reducing the dose, fine, but quitting entirely? What for—so you can repeat the whole thing 12 months from now?

The reason is simply that using GLPs to treat obesity is a relatively recent approved mode of treatment. Drug companies understand that acceptance of GLPs goes up when people believe the pitch is "use it for several months, shed the pounds, then you're finished" — which is why maintenance isn't being emphasized heavily at this stage. Right now the priority is gaining entry by securing reimbursement from health plans, and presenting the drug as short-term makes that argument far easier to win.

After pharma judges that GLPs have hit critical mass for weight-loss use and insurance coverage, it will then encourage endocrinologists — through whichever professional societies are relevant — to begin putting out formal positions on maintenance treatment. By that point, health plans will find it much harder to walk back coverage, leaving them on the hook for lifetime payment (along with the steeper premiums that follow).

 

[rpm2026]

I have reached my target weight, and stopping my GLP-1 is not something I want to do. What a sensible maintenance dose looks like is something I am still trying to work out. Feeling hungry, I have realized, is something I find appalling.

 

[byefatlicia]

rpm2026 said:

I have reached my target weight, and stopping my GLP-1 is not something I want to do. What a sensible maintenance dose looks like is something I am still trying to work out. Feeling hungry, I have realized, is something I find appalling.

Stopping isn't in my plans either. With Tirz, eating is still possible when I choose to. Right now I've hit a plateau. That's the situation... Even so, gaining weight while on it would be possible if I chose to. What Tirz provides is control over what I want or need. Being able to select just what I need instead is a massive victory

 

[rpm2026]

100% agree with you there.

 

[Calm Logic]

Candaril said:

I get both sides here — what it’s like for the patient and what it’s like for the doctor.

Mounjaro took 30% off my weight in a year, and these days I’m in maintenance.

Logically, I ought to be stepping the dose down little by little so I don’t keep shedding pounds while eating as I normally do.

Instead, I’ve been adding more calorie-dense foods to stop any more weight loss, and that’s how I’m holding steady.

Reducing the dose is just something I can’t make myself do.

Probably psychological, I think.

Zydeceltico said:

Nmcoyote1 said:

I wish I were among the 45% super responders. My loss came to 34%, yet by BMI I remain overweight. At 5’6”, my current weight is 215. Back in 2008, when I dropped 40 pounds and reached 180, my wife felt I appeared too thin. That’s why I set 190 as my target. Since roughly may 2025, progress has stalled. Right now I’m stacking 1mg Sema with 5mg Reta, hoping the scale will start moving downward once more. It seems to be working slowly.

I'm in a fairly similar bind — I hit my goal weight and started looking "too thin" while my BMI was still in "overweight" territory rather than the healthy range. At 5'-11" I'm now 185 lbs, and by BMI I'm still a few pounds into "overweight." Since cardiovascular risk is what I care about most, seeing that BMI number makes me uneasy; at the same time, my girlfriend tells me I'm getting far too skinny. When I check the mirror, I have to admit she has a point.

SOOOOOOOO........ rather than BMI, I've switched to a different, newer way of judging my overall weight health: Waist/Hip Ratio (WHR - look it up). For men, WHR ought to be around .90. Mine is .98. The thing is, I was never genetically blessed with much of a butt, so instead of trying to trim my waist further, I'm working on making my butt bigger — which translates to a LOT of heavy hip thrusts at the gym. LOL - and it's starting to show results. My butt gained 1/4" over the last 2 months. My waist is unchanged.

No need to come in here with your shiny wins and spoil our broccoli sandwich fun, haha.

lessthanhalf said:

I realize this piece came from a practising endocrinologist who is grappling with these questions in the clinic, and who has very little research evidence to lean on when deciding what should happen once weight has already come off on these drugs.

My reading is that his views are shaped heavily by older ideas about what weight loss was achievable and safe, back when keeping off 5-10% counted as a great outcome for health.

That picture no longer holds. Far better results are now within reach — not for everybody, since some people either can't handle the drugs or don't respond well — but for many, a 20% reduction is entirely attainable. What keeps striking me is how rarely I encounter people on this forum who are stalled midway to their target after shedding roughly 20%, when the trial data suggest that should describe nearly all of the more severely overweight. Even allowing for a self-selected group, plus peptide stacking and several GLP's together, it ought to turn up more often than it does.

There is a legitimate role for the worried, paternalistic tone he adopts: using these drugs without medical oversight or guidance brings added dangers, quite apart from any risk from tainted, mislabelled or counterfeit products. Dosing mistakes made through the DIY route do land people in hospital fairly regularly. Still, that outlook sits fundamentally at odds with a patient's or a person's right to make their own medical choices, and medicine has never been good at handling that tension. Obviously giving GLP's to someone with anorexia nervosa is a bad idea, but I would place the boundary between patient autonomy and paternalism much nearer the autonomy end than he does.

The long-term health evidence in people who are severely obese, diabetic, or living with heart disease is unmistakable: these drugs markedly improve health, and solid research shows the advantage grows at higher therapeutic doses rather than lower ones. That undermines the medical rationale for halting or cutting doses in some of his patients, since the evidence is equally plain that ceasing these drugs or lowering the dose brings weight back, along with the health harms that follow.

As for judging treatment by his own read of its effect on quality of life — once again, the person themselves is normally best placed to make that call, with a handful of exceptions such as serious eating disorders.

From what I've seen, most doctors carry the same prejudices toward people with severe obesity as everyone else. This doctor doesn't appear to display that, yet it's highly unlikely he grasps anything close to the full lived reality of being in that state. Severe obesity brings severe social penalties — lower income, being regarded as less than human by strangers — and those pressures, more than the health ones, are what push people to want to shed weight. With milder obesity the penalties are smaller but still far from trivial.

I believe he is missing the larger picture of his patients' lives, and that this is what tilts him toward excessive caution with these medications.

Before GLP's existed, only an astonishingly tiny slice of the population ever managed major long-term weight loss, and the rare few who did had to overhaul their lives and control food and exercise obsessively. Yet he opts to withdraw medication when it disrupts the social side of eating. Sustaining a large loss over years demands fairly obsessive control over what you eat; when nearly everyone around you eats poorly, declining the same foods will always create friction around shared meals.

I doubt I'd stay his patient for long. Having lost 54% of my weight and living on a very narrow, repetitive diet sounds a great deal like his warning signs, yet that is precisely what holding onto such a loss requires (along with some reta and 15mg of tirzepatide).

Because far cheaper pirate Chinese GLP's are so readily obtainable, his stance could drive the very people he thinks should be on lower doses or off treatment — those who reject his judgment — into the grey market.

Watching how this market has expanded over the past year or so, it will grow vastly larger ahead. The bottled-up demand from literally billions of obese people who would rather weigh less is immense, and on top of them are all those who are somewhat overweight and would rather be slimmer for fairly sensible social reasons (society judges fat people, and harshly). Legitimate versions cost so much that a black market was unavoidable, and while I expect prices to moderate in a few years as competition builds, this kind of over-paternalistic medical posture drives people away from the medical route and toward the grey or black market. That does bring added risks, chiefly from other related medical problems going untreated — optimal management of blood lipids, diabetes and pre-diabetes, and hypertension — as well as from exposure to, and possible use of, an entirely different set of peptides that for the most part have no human trials showing they work or are safe.

That doctor’s remark about social gatherings struck me as strange as well, because plenty of diets (religious and ethical ones included) are already anti-social, vegan diets being one example.

 

[GLP1Pharmacist]

I came out ahead of that 45% figure she’s encountered, yet I get that emotionally it can take longer to catch up than the physical change itself. Someone who quits drinking is still an alcoholic in their own view. So in a certain way, maybe people who see themselves as fat never fully shed that feeling.

 

[randompersonrandom]

Sasquatch said:

randompersonrandom said:

It’s odd that they frame it as "stopping," as though that wouldn’t just lead to regaining the weight, which we basically KNOW will happen. Reducing the dose, fine, but quitting entirely? What for—so you can repeat the whole thing 12 months from now?

Does this group—those of us here on this forum—even register as real to doctors who are licensed and practicing? We hold a mountain of information since we guide ourselves. Yet I doubt a single physician could show up here, within the rules of their license, just to pick up what we, this community, have learned.

tubby said:

randompersonrandom said:

It’s odd that they frame it as "stopping," as though that wouldn’t just lead to regaining the weight, which we basically KNOW will happen. Reducing the dose, fine, but quitting entirely? What for—so you can repeat the whole thing 12 months from now?

The reason is simply that using GLPs to treat obesity is a relatively recent approved mode of treatment. Drug companies understand that acceptance of GLPs goes up when people believe the pitch is "use it for several months, shed the pounds, then you're finished" — which is why maintenance isn't being emphasized heavily at this stage. Right now the priority is gaining entry by securing reimbursement from health plans, and presenting the drug as short-term makes that argument far easier to win.

After pharma judges that GLPs have hit critical mass for weight-loss use and insurance coverage, it will then encourage endocrinologists — through whichever professional societies are relevant — to begin putting out formal positions on maintenance treatment. By that point, health plans will find it much harder to walk back coverage, leaving them on the hook for lifetime payment (along with the steeper premiums that follow).

Sure, but...SURMOUNT actually took place. Everyone watched it unfold. They keep acting like it never occurred, yet it did, and to me that's just astonishing.

 

[AYarter]

I had wanted to quit, yet the effect on my inflammation is extraordinary.

TA1 could be worth looking into for that, but what matters most to me is keeping the inflammation relief.

That’s why I’ll remain gray....

 

[Chili777]

GLPs deliver more than just weight loss. For me, losing the urge to drink alcohol ranks almost as high as the weight I've lost. Since I began Reta, other unhealthy behaviors have also dropped away. I've always maintained that I'll keep some on hand for life purely for that benefit, and that holds true even if I could stay at a healthy weight without it—which probably wouldn't happen anyway.

 

[Batscout]

Calm Logic said:

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



Some GLP-1 patients are begging to stay on the drugs just a little bit longer, presenting an ethical dilemma for doctors.

View attachment 11016


www.statnews.com

We’ve gone from weight loss drug shortages to a problem of excess — and eating disorders​#-weve-gone-from-weight-loss-drug-shortages-to-a-problem-of-excess-and-eating-disordersBy Jody Dushay, MD

Feb. 19, 2026

...From what I have seen in practice, those on GLP-1 therapies can be grouped into a few distinct groups.

For most — the average responders — body weight drops by 10% to 20% across six to 12 months, and with continued treatment, the bulk of that loss is maintained.

Roughly 5% either cannot tolerate any GLP-1 medication or show no response at all: their weight loss is minimal or absent, or side effects force them to quit.

A further approximately 5% of my patients are super responders, shedding over 25% of their body weight. I have witnessed figures as high as 45%. Genetics probably play at least some role in why certain people fail to respond — or respond excessively — to pharmacologic levels of GLP-1. As of now, no straightforward blood test exists that can forecast how strongly someone will respond.

Sooner or later, at the maximum tolerated GLP-1 dose, every person hits a weight loss plateau. And hardly anyone has told me that the weight at which they plateau is their Goldilocks weight. It happens often that people grow so focused on a particular scale reading that they overlook the enormous gains they have made in overall health. Nearly all of them want to lose more, and I am figuring out in real time how best to support patients whose plateau weight is above what they had envisioned when starting treatment. It feels to me like telling someone who trained for a marathon to be content after 10 kilometers.

What I find hardest, though, is helping people grasp why I believe they have shed too much weight, and why in certain cases I put my foot down about stopping or sharply reducing their GLP-1 dose. The negotiation becomes really tough when someone suggests, “How about if I just stay on the same dose for another few months, in case I gain weight on vacation/after menopause/over the holidays?”

As an endocrinologist, treating eating disorders or disordered eating is not part of my professional training, yet I recognize both when they appear, and sadly I am seeing them with growing frequency.

For individuals dealing with intrusive cravings, relentless food thoughts, and a dulled sense of fullness, GLP-1 therapies are unquestionably transformative. That said, a total absence of appetite is abnormal and goes beyond what GLP therapies ought to produce. The same holds for fear of food and fixation on a particular weight. Red flags include stress at home around mealtimes, friendships strained because social gatherings involving food feel uncomfortable, or a partner, child, or parent believing someone has developed highly abnormal eating habits.

Because they don’t want to reduce their dose or quit the medication, some of my patients downplay GLP-1 side effects — a choice that can result in serious complications. I do not routinely track longitudinal changes in body composition or bone mass among people on GLP-1s, largely because DXA scans are costly, but substantial muscle or bone loss are two objective signs of excessive weight loss that ought to prompt stopping or slowing treatment.

To be sure, I respect that weight loss is a struggle for these patients, and I prescribe and advocate for medication to help people lose weight.

But I am also responsible when a physical or mental health threshold has been crossed. We live in a society where weight is seen as a readout of health, which is as inaccurate as it is unfortunate. Weight and BMI are only one metric of physical and emotional health. Just as important are what a person puts into and does with their body at any weight. The cutoffs for healthy weight based on body mass index (BMI) are plagued by the shortcomings of BMI itself, which should not be used as the only determinant of complicated obesity.

So how do I decide in the moment if a person in front of me is at a healthy weight? I use a collection of objective measurements such as cholesterol levels, blood pressure, waist size, blood sugar, and liver function to support my clinical judgement. I also ask patients what they eat over the course of a typical day, how much physical activity they get, and if they have enough energy to do things they enjoy...

When treatment begins, I aim to learn why someone wants to lose weight, and I steer clear of assigning a numeric weight loss target. Excessive weight loss is real, and my hope is that it will not become something I encounter more frequently as a consequence of GLP-1 therapies.

This article describes people like me.