My biggest GLP-1 ethical problem: patients who don’t want to stop
- Thread starter Calm Logic
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Calm Logic
Explorer
Is that not justified? GLP-1s target the biological drivers — intense hunger or constant food thoughts — that can interfere with clear thinking. When your body is in a stressed or dysregulated state, sticking with lasting lifestyle changes becomes very difficult. And every person using GLP-1s has already tried diet and exercise. To me, these drugs aren't merely a tool. They're a long-term, essential medication.
Sure, better eating habits and physical activity do help, and they can improve lab results (as can GLP-1s), blood pressure (as can GLP-1s), and allow for a reduced maintenance dose. Plus, resistance training obviously helps guard against muscle loss:
Obesity is being accepted more and more by the medical field as a chronic medical condition rather than something a person has failed at. Society, however, has not fully caught up.
For me, GLP-1 therapy targets a metabolic dysfunction that sits underneath. Stopping treatment, in my expectation, would mean going back to where I started. That said, obesity has been part of my whole life, and I have fought it for decades. Some people whose metabolic dysregulation is milder might hold onto their results without medication, but in my own case I know long-term therapy is required.
lessthanhalf
Explorer
I am all too familiar with how difficult it is to keep off a large amount of weight once GLP medications are out of the picture. In 2013 I went from 120 or 130 kg down to 65kg, and I held that for 2 years. In the end, though, I simply could not keep eating the way I needed to, and the familiar thought that just 1 serving of ice cream is harmless — and where that thought leads me, at least — took over.
Then I repeated the whole thing in 2022 - 2023, going from 145 to 75kg, and that stayed off for a year.
Once I began semaglutide, I believe I felt for the first time in my life what it is like to be too full to clean my plate. For a year I tolerated nausea and feeling somewhat unwell in return for lower hunger, until I thankfully found less expensive Chinese options that suppressed appetite better and caused fewer side effects.
To my considerable surprise, I am still losing weight very gradually, 100-200g each week, without having to make a constant conscious effort to eat less than I want. At 66kg and a bmi of 24, I am not completely certain where I should stop. Eventually, at my current doses, either the weight loss will plateau, or I will need to choose a weight and reduce reta and tirz somewhat, or cut back some of the other peptides I have added for possible extra effects on appetite/weight - Adamax for alpha MSH, low dose HGH, oxytocin, and mots-c. Even though the receptor effects underneath are fairly well understood, I genuinely do not know how much any of these are doing, since none have ever been studied in humans for weight loss, and I will have to stop them at some point and watch what happens to my weight or hunger. I never plan to stop Tirzepatide or Reta.
Then I repeated the whole thing in 2022 - 2023, going from 145 to 75kg, and that stayed off for a year.
Once I began semaglutide, I believe I felt for the first time in my life what it is like to be too full to clean my plate. For a year I tolerated nausea and feeling somewhat unwell in return for lower hunger, until I thankfully found less expensive Chinese options that suppressed appetite better and caused fewer side effects.
To my considerable surprise, I am still losing weight very gradually, 100-200g each week, without having to make a constant conscious effort to eat less than I want. At 66kg and a bmi of 24, I am not completely certain where I should stop. Eventually, at my current doses, either the weight loss will plateau, or I will need to choose a weight and reduce reta and tirz somewhat, or cut back some of the other peptides I have added for possible extra effects on appetite/weight - Adamax for alpha MSH, low dose HGH, oxytocin, and mots-c. Even though the receptor effects underneath are fairly well understood, I genuinely do not know how much any of these are doing, since none have ever been studied in humans for weight loss, and I will have to stop them at some point and watch what happens to my weight or hunger. I never plan to stop Tirzepatide or Reta.
randompersonrandom
Explorer
Absolutely agreed. When someone starts lecturing me with "you have to change your lifestyle!" I just let it go — I don't get into online debates unless there's a paycheck involved, and in everyday life I simply don't have the time or energy to engage, since far more people want my attention than I could ever accommodate. So I reserve my conversations for those who aren't just repeating tired, oversimplified clichés.
That said, Patricia, obviously losing weight and keeping it off requires me to "change my lifestyle." But it isn't a one-time switch, or even a monthly one, where you declare "YAY, LIFESTYLE CHANGED" and then forget about it. It's ongoing maintenance — which sounds inspiring phrased that way, but in reality means "consume less food than I desperately want, every hour of every day, indefinitely, while suppressing my intense urge to eat as much as I crave," because we all know you can't outrun your fork. So fine, Patricia, the meds let me "change my lifestyle" and everyone's satisfied — what exactly are you going on about?
(That said, cheers to the rare unicorns who can use these meds as a springboard and then keep the habit going once it's been part of their life long enough. That's not me and I doubt it ever will be, but good for you if it is.)
lessthanhalf
Explorer
Nearly every person here has, at some time in their life, dropped pounds without GLP's. It isn't extremely difficult: you simply make the choice to follow a diet and keep following it, and just about anyone can manage that for a period.
What makes the "change you lifestyle" answer fail isn't that it's impossible — it's the relentless mental strain it demands. Realistically, if you could sustain that diet or way of living without a great deal of ongoing mental labor, you wouldn't be obese in the first place. And in time, practically everyone's capacity to keep exerting that effort gradually erodes. Should you manage to build new habits that no longer call for that unending effort, then the issue is solved — yet the research and the lived experience of most people indicate this happens so rarely that only a tiny number pull it off. When your appetite regulation system can't handle a constant supply of cheap, readily available, high calorie, highly rewarding food that it never evolved to handle, then the sole way to avoid overeating is unending effort — and sooner or later that supply of effort is exhausted.
Fortunately, GLP's don't demand unending effort in order to function; all that's needed is an injection roughly once a week. That sidesteps the entire difficulty, and in fact makes creating and maintaining genuine, meaningful, long term lifestyle changes far simpler and far more probable. A straightforward illustration: exercising is vastly easier when you aren't morbidly obese. So quitting them upon reaching a goal weight actually places those beneficial lifestyle changes, along with the weight loss, in jeopardy. I'm not claiming nobody should ever attempt to stop them, but with severe longstanding obesity, I believe it's a poor choice.
What makes the "change you lifestyle" answer fail isn't that it's impossible — it's the relentless mental strain it demands. Realistically, if you could sustain that diet or way of living without a great deal of ongoing mental labor, you wouldn't be obese in the first place. And in time, practically everyone's capacity to keep exerting that effort gradually erodes. Should you manage to build new habits that no longer call for that unending effort, then the issue is solved — yet the research and the lived experience of most people indicate this happens so rarely that only a tiny number pull it off. When your appetite regulation system can't handle a constant supply of cheap, readily available, high calorie, highly rewarding food that it never evolved to handle, then the sole way to avoid overeating is unending effort — and sooner or later that supply of effort is exhausted.
Fortunately, GLP's don't demand unending effort in order to function; all that's needed is an injection roughly once a week. That sidesteps the entire difficulty, and in fact makes creating and maintaining genuine, meaningful, long term lifestyle changes far simpler and far more probable. A straightforward illustration: exercising is vastly easier when you aren't morbidly obese. So quitting them upon reaching a goal weight actually places those beneficial lifestyle changes, along with the weight loss, in jeopardy. I'm not claiming nobody should ever attempt to stop them, but with severe longstanding obesity, I believe it's a poor choice.
A nuance I think gets overlooked in this discussion: while every diet involves some level of restriction, not every diet means you're constantly battling hunger.
The typical "low calorie" route is likely the most wretched and the one most destined to fail (except in uncommon cases). Why? If you continue consuming the same hyper-palatable, addictive junk as before, merely cutting yourself off at 30% less each day until you give in. Anyone whose experience stops at this method could be excused for concluding that dieting as a concept simply cannot work.
A bit less wretched is the low-fat world, which tends to push more toward plant-like foods and away from heavily refined grains. You have to get over an initial hump, something like withdrawal from your favorite processed foods. On such a diet you can feel full while dropping weight, though true satiety might still be hard to reach. Hunger won't be the issue — rather, it's a sense of missing particular foods and the feelings tied to them.
Less wretched still (though plenty would argue) are the various low-carb approaches — some leaning more or less meat-based, others toward plants and/or dairy, and some emphasizing higher fat. For me, these were the simplest for losing and keeping weight off, but boy did I miss potatoes!
On top of these diets, one could layer fasting adjustments, which to the uninitiated probably sounds absurd (isn't hunger the very definition?), whether that's time-restricted eating or scheduled days without food.
Each of these demanded sacrificing something, yet many sidestepped the issue of relentless hunger.
The typical "low calorie" route is likely the most wretched and the one most destined to fail (except in uncommon cases). Why? If you continue consuming the same hyper-palatable, addictive junk as before, merely cutting yourself off at 30% less each day until you give in. Anyone whose experience stops at this method could be excused for concluding that dieting as a concept simply cannot work.
A bit less wretched is the low-fat world, which tends to push more toward plant-like foods and away from heavily refined grains. You have to get over an initial hump, something like withdrawal from your favorite processed foods. On such a diet you can feel full while dropping weight, though true satiety might still be hard to reach. Hunger won't be the issue — rather, it's a sense of missing particular foods and the feelings tied to them.
Less wretched still (though plenty would argue) are the various low-carb approaches — some leaning more or less meat-based, others toward plants and/or dairy, and some emphasizing higher fat. For me, these were the simplest for losing and keeping weight off, but boy did I miss potatoes!
On top of these diets, one could layer fasting adjustments, which to the uninitiated probably sounds absurd (isn't hunger the very definition?), whether that's time-restricted eating or scheduled days without food.
Each of these demanded sacrificing something, yet many sidestepped the issue of relentless hunger.
lessthanhalf
Explorer
I fully agree with the idea of figuring out an eating pattern that keeps hunger in check and lets you consume enough that you aren't perpetually limiting portions, largely because that approach is simply difficult and tends to collapse in the end.
A ketogenic, low carb, or even the old Atkins plan I recall attempting years ago offers the benefit that ketones blunt appetite, and having steadier blood sugar, insulin, and a whole set of other hormones and neurotransmitters tied to hunger regulation makes it simpler to maintain and stops the sharp hunger surges that make losing self control far more probable. In certain ways I believe Atkins had some correct insights, even though the reality is far more complicated than he imagined. It's notable that these days continuous glucose monitors frequently reveal glucose rises after energy dense meals, then drops that drive more hunger, essentially the mechanism Atkins proposed 40 years ago.
The difficulty is that a high fat way of eating tends also to be energy dense, so portions are small, which doesn't address hunger. Plus the evidence on ketogenic diets appears to have flipped repeatedly across recent decades regarding health effects. They also typically fall short on fiber and plant foods.
When it comes to disease prevention, the eating pattern with by far the strongest evidence is the mediterranean diet, or close variations on it.
My own simple idea about obesity centers on low energy density, under 1.5 kcal/g, as the key factor, so you can eat as much as you want or need without hunger, and adding a solid proportion of protein makes it even better. Almost all processed foods are too energy dense, and this rules out nearly all high carb items such as bread and grain products, while permitting essentially unlimited fruit and vegetables, even though they are mostly carbs or sugar, because it is trapped in cell structures and fiber and therefore absorbed far more slowly than from things like bread or biscuits. It also lets you graze all day on fruit—maybe not bananas—but a kilo of fruit is usually only 500 kcal or less and is a substantial amount to eat across a day. Very lean meat fits and is the strongest appetite suppressor per calorie.
Fitting fat into this is tough, since even modest quantities immediately raise calories per gram sharply. And the extra calories from small fat additions can be big—55 grams of oil has calories comparable to a kilo of fruit. If that were my only food for a day, I'd choose the fruit over the oil. A very low fat diet isn't automatically unhealthy but should ideally include some fish and olive oil. Since I appear to need to keep intake below that of an average 66kg 58yo male, maintaining weight on 1600-1800 kcal/day because of metabolic adaptation to long term calorie restriction, I have little room to add calories. Quite a few studies back up this way of eating, though it is far from the standard view.
One issue I've encountered is that I must be very cautious about eating anything that could disrupt this system. Small amounts of rich food will skew your preferences so lower calorie foods taste worse, and it risks those hunger spikes that are hard to manage.
A ketogenic, low carb, or even the old Atkins plan I recall attempting years ago offers the benefit that ketones blunt appetite, and having steadier blood sugar, insulin, and a whole set of other hormones and neurotransmitters tied to hunger regulation makes it simpler to maintain and stops the sharp hunger surges that make losing self control far more probable. In certain ways I believe Atkins had some correct insights, even though the reality is far more complicated than he imagined. It's notable that these days continuous glucose monitors frequently reveal glucose rises after energy dense meals, then drops that drive more hunger, essentially the mechanism Atkins proposed 40 years ago.
The difficulty is that a high fat way of eating tends also to be energy dense, so portions are small, which doesn't address hunger. Plus the evidence on ketogenic diets appears to have flipped repeatedly across recent decades regarding health effects. They also typically fall short on fiber and plant foods.
When it comes to disease prevention, the eating pattern with by far the strongest evidence is the mediterranean diet, or close variations on it.
My own simple idea about obesity centers on low energy density, under 1.5 kcal/g, as the key factor, so you can eat as much as you want or need without hunger, and adding a solid proportion of protein makes it even better. Almost all processed foods are too energy dense, and this rules out nearly all high carb items such as bread and grain products, while permitting essentially unlimited fruit and vegetables, even though they are mostly carbs or sugar, because it is trapped in cell structures and fiber and therefore absorbed far more slowly than from things like bread or biscuits. It also lets you graze all day on fruit—maybe not bananas—but a kilo of fruit is usually only 500 kcal or less and is a substantial amount to eat across a day. Very lean meat fits and is the strongest appetite suppressor per calorie.
Fitting fat into this is tough, since even modest quantities immediately raise calories per gram sharply. And the extra calories from small fat additions can be big—55 grams of oil has calories comparable to a kilo of fruit. If that were my only food for a day, I'd choose the fruit over the oil. A very low fat diet isn't automatically unhealthy but should ideally include some fish and olive oil. Since I appear to need to keep intake below that of an average 66kg 58yo male, maintaining weight on 1600-1800 kcal/day because of metabolic adaptation to long term calorie restriction, I have little room to add calories. Quite a few studies back up this way of eating, though it is far from the standard view.
One issue I've encountered is that I must be very cautious about eating anything that could disrupt this system. Small amounts of rich food will skew your preferences so lower calorie foods taste worse, and it risks those hunger spikes that are hard to manage.
Calm Logic
Explorer
That's the way I see it. Take the typical poor American way of eating — meat and potatoes. Certain diets cut back on the meat (plus other animal proteins), while others cut back on the potatoes (plus bread and rice). Sitting in between is the Mediterranean diet, which the American Heart Association endorses:
And, naturally: "Two people can eat the same food and have very different hormonal responses."
I appreciate how much effort went into laying all of that out, and a large portion of it is genuinely solid and thoughtful. With most of it I'm either fully on board or only split on small details (for instance, my threshold for what counts as a good "fruit" might sit somewhere else, and neither of us would be wrong, because that's a judgment call). What stood out to me in particular was that you framed fruits and vegetables in terms of their intact cellular matrix instead of reducing it to "fiber," a distinction far too many people gloss over.
A few things I'd push back on:
Even though it runs against intuition, I'd place both low-calorie-density approaches and most interpretations of the "Mediterranean" diet (a label with a rather slippery definition) into the same bucket as "low-fat" diets. I realize that sounds off, since neither one is intrinsically low-fat, and maybe the blame is mine for naming the category that way. My point is simply that what a person actually experiences on either of those plans tends to resemble the low-fat experience: you can end up full, yet you're generally less likely to feel satisfied. That's exactly why I leaned toward the low-carb umbrella myself, because it gave me a shot at satiety.
Within low-carb/keto, I think a big part of getting it right means discarding the calorie framework altogether and concentrating instead on steering clear of "really good" foods that carry more addiction potential, so to speak, while favoring foods that don't hijack your built-in hunger signaling. Sure, CICO holds true in hindsight, but if you try to engineer those diets to be low-calorie, you lose everything they have to offer. As you pointed out earlier, deliberately going low-calorie usually works against self-control, so if you've built some low-calorie version of Atkins, you're essentially tossing out what makes Atkins work: it's a plan where you eat until full (provided you're picky about which foods you choose and remain inside those limits). It may not deliver a 6-pack of abs before you plateau, but for most people it will land them at a better weight than where they are now. Also, a fun bit of trivia for you: 100 years before Atkins made his diet famous, a man named William Banting made a quite similar diet famous, which people at the time called the Banting diet.
I'd also agree that the theories underpinning the various low-carb ideas keep shifting and will likely keep shifting. One very unusual version of that concept, not widely known, that I see as an interesting proof of concept is the ex150 diet. The person behind it is a blogger who enjoys testing different diets and writing them up. I wouldn't call him an expert, but he's extremely persistent and equally meticulous about logging highly detailed data on what he does. The reason I think it might catch your interest is that his main/default daily diet is heavy cream (alongside some beef and a small amount of vegetables). He eats it to satiety every day and has dropped significant weight on it, after failing to find lasting success with other ketogenic diets. I don't agree with a fair amount of his personal analysis, but that's not why I follow him. I just find his results to be very interesting.
The amount of mental energy required to keep off a large amount of weight is something most people severely underestimate. Your post brings back something I heard a few months ago, when I happened to catch a fitness bro–type influencer on a random TikTok live. What he said has stayed with me. His viewers were pushing him to criticize people using GLP1s, and his response was honestly IDGAF and good for them. He continued by saying that sure, people can white knuckle it and pour every ounce of mental effort into losing weight, but after that they can't live the rest of their life. With a GLP1, those people get to live their lives and fix their bodies. It stuck with me both because it was correct and because he wasn't someone I would have expected to get that.
peppystrings80
Explorer
Feeling the same way — that makes two of us! No midnight chocolate splurges at all.
RoadRash
Explorer
That's my take too. I picked up the same thing from it. He comes across as truly worried about the people under his care.