What does the science actually say about GLP-1 drugs for weight loss?

GGLP-1 medications like semaglutide (Ozempic, Wegovy) and tirzepatide (Mounjaro, Zepbound) were originally developed as type 2 diabetes medications. The weight loss use came later, when pharmaceutical companies found that higher doses produced greater weight loss and pivoted toward that market. The weight loss doses are significantly higher than the therapeutic diabetes doses — in the case of semaglutide, the most recently approved weight loss dose of 7.2 milligrams is up to 14 times the minimum effective diabetes dose. Maximizing the drug’s weight loss side effect means simultaneously maximizing all other dose-dependent side effects, some of which are serious and in some cases fatal.

The average weight loss reported in clinical trials is approximately 15 percent for semaglutide at 2.4 milligrams and approximately 20 percent for tirzepatide. However, roughly half of trial participants lost less than the reported average, and 13 to 15 percent of semaglutide users and 3 to 5 percent of tirzepatide users did not lose even 5 percent of their body weight. Weight regain after stopping the drug is well documented and occurs more rapidly than regain following behavior-based interventions. An additional concern is that 20 to 50 percent of the weight lost on these medications is muscle mass, which is not typically recovered when weight is regained, resulting in a net change in body composition that can affect long-term mobility and health.

Secondary use claims — including cardiovascular protection, kidney function, and neurological benefits — are an active area of pharmaceutical research, but the evidence base is mixed. The semaglutide cardiovascular trial, for example, enrolled participants who were 45 and older with pre-existing heart disease and a BMI of 27 or higher. Results were only statistically significant for white and Asian men with an average age of 61.6 and were not statistically significant for women, Black people, Hispanic people, people under 55 or over 75, or those with a BMI over 35. FDA approval was nonetheless granted for adults broadly with overweight and obesity. There is currently no approved use and no substantial research base for microdosing.

For practitioners working from a weight-inclusive framework, the central issue is that most clinical research on GLP-1 medications does not include a weight-neutral comparator group — both arms of most trials are placed on a caloric deficit. This makes it difficult to assess what portion of any observed health benefit comes from the drug itself versus behavior change or the drug’s direct physiological effects independent of weight loss. Research consistently shows that health benefits observed in GLP-1 studies often occur before significant weight loss or in the absence of it. Practitioners and individuals should ask for full informed consent conversations that include how the drug compares to existing treatments, what realistic outcomes look like, and what the dose-and-titration plan is for the specific health condition being addressed.

Transcript 

[00:05:23] Stephanie: For those who may not know you, can you introduce yourself?

[00:05:23] Ragen Chastain: Sure, so hey, my name is Ragen Chastain, my pronouns are she, her. I’m a speaker, writer, and researcher, and my area of expertise is the intersections of weight science, weight stigma, and healthcare practice. So I’ve been studying the research around weight and health now for over 20 years. I’ve been doing the speaking, writing, and researching full-time since 2012. And my primary audience is healthcare providers, and it can be things as general as creating a welcoming environment for higher-weight people, to things as specific as anesthesia practice. So I get to do a lot of things. I get to go to a lot of fun conferences and hear all the doctor stories. I’m not myself a medical doctor, so just get that out of the way. And so yeah, that’s sort of the little corner I’ve carved for myself.

[00:06:41] Stephanie: How did you get to that specialty of work?

[00:06:41] Ragen Chastain: Yeah, kind of accidentally. So, my training is in research methods and statistics. That was my original undergraduate college training. And I actually started for myself — I had been yo-yo dieting for years, and so I decided I wanted to find the weight loss method with the highest efficacy. And so I decided to undertake a literature review of the weight loss research. I was not in school at this time. I didn’t undertake it to publish. This is how I solve my life problems. This is the kind of mega nerd that I just am.

[00:07:07] Ragen Chastain: And so I did this full literature review, and I got to the end, and I had all the emotions — surprise, anger, disbelief, defensiveness, incredulousness — to the point that I did the whole thing a second time. I was doing calculations by hand, I was trying to figure out how I misunderstood this body of research, because what I found was that there wasn’t a single study where more than a tiny fraction of people were actually experiencing anything resembling significant long-term weight loss, and that the vast majority of people were losing weight and gaining it back, which is exactly what happened to me. And that’s what started me down the rabbit hole.

[00:07:47] Ragen Chastain: And then I became a ballroom dancer. And I had a judge tell me repeatedly she couldn’t stand to look at me because my arms were showing in my waltz gown. And that’s when I realized I had done a ton of activism in college. I’m a queer person, and I had done a lot of queer and trans activism. But I never thought of fat people as a group of people who were oppressed. And so in that moment, as that judge told me repeatedly she couldn’t stand to look at me, I was like, oh — I had the light bulb moment of, no, this is an oppression, and at the time, so embarrassing, I didn’t know there was this huge community that had been going strong since well before I was born. And so I started a little blog called Dances with Fat, just to talk about my experience, and then it widened out.

[00:08:41] Ragen Chastain: And I started talking a lot about fat civil rights and digging into the research, because I had that background. And then, essentially, I got a request from some people of color within the community that it was just too much me — I was blogging literally 7 days a week, I was speaking on a ton of topics. And so I said, well, what would be the most helpful? And the suggestion that came back was if I focused in on the research around weight and health, and so that’s kind of how I moved into this as a specialty and just started doing this every day. That’s when I started the Weight and Healthcare newsletter and all of that.

[00:09:58] Stephanie: Okay, so we want to do this interview with the intention of giving, as of May the 15th, 2026, the highest level possible of where we stand with the research associated with GLP-1. I want to get at the highest level the state of affairs on GLP-1 research as of now. Start with that.

[00:10:40] Ragen Chastain: Okay, so the big overarching thing is that, first of all, these are solid drugs for type 2 diabetes. They may not necessarily be frontline drugs, because they do have more side effects and more serious side effects than some other drugs. But they work well for people who are contraindicated for other drugs, they work well for people who couldn’t get the glycemic management they were looking for on other drugs. There’s a good amount of research around safety at the type 2 diabetes dose. So these are solid type 2 diabetes drugs. Want to start there.

[00:11:15] Ragen Chastain: What happened was, at the same time that these drugs were showing kind of a little bit of weight loss in patients with type 2 diabetes, Eli Lilly and Novo Nordisk — who were two of the three companies that were essentially price gouging insulin to make a fortune, especially here in the States — learned that the government was planning to put price controls, and so they were gonna lose that profit. And at that time, the CEO of Novo Nordisk said, we’re taking a bet on, quote, obesity, and we will create the market. And so, they were like, okay, well, these drugs at the type 2 diabetes dose create a little bit of weight loss — what if we gave people a megadose? Would that create more weight loss? And it did. And that’s how it became quote-unquote weight loss medication.

[00:12:05] Ragen Chastain: So the thing about that is the weight loss is a side effect of the type 2 diabetes medication. And so, when we dose and titrate for type 2 diabetes, the goal is to give the minimum dose that’s needed to get the glycemic management someone wants, and to minimize the side effects of the drug, which, again, can be serious and even fatal. With weight loss, the goal is to get the person up to the maximum dose they can possibly tolerate, or the maximum dose allowed, preferably, to maximize the side effect of weight loss. And you can’t do that without maximizing all the other dose-dependent side effects.

[00:12:44] Ragen Chastain: For semaglutide, for example, the minimum therapeutic type 2 diabetes dose is 0.5 milligrams. The recommended weight loss dose originally was 2.4 milligrams. The maximum type 2 diabetes dose used to be 1mg. Here in the States, it’s been pushed to 2, but a lot of places outside of the States, it’s still 1mg. So we’re talking about almost two and a half times that original maximum dose, almost five times that original minimum dose. And then, most recently, they have approved semaglutide at 7.2 milligrams — so 14.4 times that minimum effective type 2 diabetes dose. And for that larger dose, you get more side effects, more of some specific side effects, and people lost about 8 to 9 additional pounds. But at the prices that Novo Nordisk’s pharmacy charges, they would have paid about $900 for those 8 to 9 pounds.

[00:14:33] Stephanie: Because I just want to pause you, so for everybody to be clear — some people listening to this may not be aware of the systemic problem here of capitalism. The reason why it’s 1mg in Canada and 2 milligrams in the States is most likely due to profitability of those pharmaceutical companies. When the minimum dose is twice the amount, they sell twice the amount of medication. Because we have the same human body in both countries, so there’s something driving the difference. So when we’re talking about higher doses, we just mean more profit. Is that your perspective on this as well?

[00:14:49] Ragen Chastain: In many cases, yes. The FDA seems to be a little more willing to go for increased doses to approve secondary uses on research that is not as strong as I would suggest it should be in order for that approval. So it may well be a profit interest of the company. And here in the States, they’re allowed to market drugs directly, so there’s a ton of commercials for these drugs. So people are meant to go in and ask their doctor to put them on the drug, and providers are telling me there has been a flood of people asking for or even demanding the drug, to the point that one of the things that they’re doing is sort of pulling the idea of patient-centered care to suggest that you should give the patient what they want. Informed consent conversation, and then whatever they want. And of course, that becomes a really dangerous thing, because patient-centered care is still always rooted in ethical, evidence-based medicine.

[00:16:08] Ragen Chastain: Alright, so we’ve got the type 2 diabetes use, we’ve got the weight loss use. So then what happened is, here in the States, after the Fen-phen tragedy — where the weight loss drug Fen-phen killed a bunch of people, harmed a bunch of people — Medicare said, we’re not covering weight loss drugs anymore. But, they were able to carve out a loophole if the weight loss drug was also approved for another use, and the person had that condition, then the weight loss drug could be approved and paid for by Medicare. And that’s when we started to see a ton of these secondary uses. It’s good for cardiovascular effects, it’s good for kidney function, et cetera, et cetera. And so that’s sort of where we started to see a lot of these secondary use approvals.

[00:17:00] Ragen Chastain: At that time, what they were doing was only testing the weight loss dose. Because that’s all they were interested in. So, for example, with cardiovascular use, they found a small effect, about 1.5% difference for people who use the weight loss dose. They actually found a larger effect in a previous study at 0.5 and 1 milligram. But that previous study was in people who had type 2 diabetes, so that could also be part of what explains having that larger effect. But at any rate, even though they had a study that showed an effect — again, it was about 2.3%, so still not a massive effect — they did not test those lower doses for the secondary use of cardiovascular prevention of major adverse cardiac events. And so a lot of these secondary use studies are only testing it at this largest weight loss dose.

[00:18:11] Ragen Chastain: What happened was — so we’ve got semaglutide, that’s Novo Nordisk’s drug. Tirzepatide is Eli Lilly’s drug, and tirzepatide is actually a co-agonist, GLP-1 and GIP. And it creates more weight loss. And so, funny beef between these — Novo Nordisk has been better at marketing, they’ve got a lot more attention. People say Ozempic to mean GLP-1 drugs, it’s like the Kleenex of GLP-1 drugs. And so Eli Lilly was like, but wait, our drug makes more weight loss. So they actually created a randomized controlled trial — and I cannot express how expensive these are — that just basically repeated their original approval trial and semaglutide’s original approval trial, just to show the exact same results again, to get more marketing about it. And so I lay awake at night and think of what I could do with that kind of money for research that they spent just to repeat two trials that were already done, just so people would say, look, we have more weight loss.

[00:19:34] Ragen Chastain: So, the average for 2.4 milligrams of semaglutide is about 15%. Now, crucially, about half the people in the trial lost less than that. And regularly, about 13-15% don’t even lose 5%. And with tirzepatide, it was about 20%. And again, about half the people lost less than that, and about 3-5% don’t lose even 5%. And this is critical because they keep touting these averages. And then, somehow the message becomes, well, you can just lose however much weight someone wants or needs to lose. And there are patients who are sort of forced into these drugs, because of BMI-based denials of care — they desperately need a knee surgery and so they’re told, we won’t operate on you at this size, so take these weight loss drugs. Or have weight loss surgery, which is ridiculous — it’s unsafe to do surgery at your body size, so let’s recommend weight loss surgery.

[00:21:03] Ragen Chastain: One of the things I’m seeing — I had 3 different patients who needed to lose 40% of their body weight to be considered worthy of surgery, based on this BMI-based denial that holds their healthcare hostage for a weight loss ransom. And they were all recommended to semaglutide. There’s almost no chance that they’re going to experience 40% weight loss, even temporarily before they start gaining it back.

[00:21:40] Stephanie: When we look at the weight loss — 15-20% average, for some people — is it sustained?

[00:22:06] Ragen Chastain: So, no, and here’s the thing. They made a weight loss drug that is in many ways like every other weight loss drug. You lose some weight when you take it, as soon as you go off, the weight comes back. Now, with these drugs, the weight comes back much faster than with behavior-based weight loss interventions. Everybody regains the weight — almost everybody regains the weight — but it’s regained much faster with these drugs. Also, with these drugs, we’re seeing 20-50% of the weight loss is muscle mass. And so, then when people regain the weight, they don’t regain the muscle mass, so it’s a drug-induced body composition shift for the vast majority of people, where they end up the same weight or possibly heavier than when they started, with less muscle mass. And I don’t think there’s anything wrong with being fat or becoming fatter, but in terms of mobility, in terms of especially our elder years, muscle mass is very important.

[00:23:05] Ragen Chastain: So, the tirzepatide withdrawal trial actually looked at weight regain among people who stayed on the drug. What they did was put everybody on the drug for 36 weeks. Over the next 52 weeks, they took half the people off the drug, left half the people on the drug. People who went off the drug regained the weight. People who stayed on the drug — 10.5% of those people regained more than 20% of the weight that they had lost in the first 36 weeks, over the next 52 weeks, while still on the drug. Critically, everybody else may have regained up to 19.9% of the weight that they lost, but we don’t know, because the researchers defined maintained weight loss as having regained less than 20% of the weight. Which is like — if I told you I started the race in first place and I maintained that, you would say, congratulations on winning the race. And if I said, oh, no, I didn’t win, but I came in 19th place, but not 20th, you would say, what are you doing? That’s kind of the kind of manipulation we see in the research.

[00:24:39] Ragen Chastain: So, with these drugs, what they did was say, okay, we can’t create a drug that actually maintains weight loss. So we’re gonna change the definition of fatness. And that’s where we’re seeing quote-unquote obesity is a chronic, lifelong, relapsing, remitting disease. And that makes up for all the shortcomings of these drugs. Oh, you don’t go off of it because it’s a chronic disease. And we keep hearing, like asthma, or like hypertension. But it’s not like asthma or hypertension, because they have defined criteria with no overlap. You either have it or you don’t. With quote-unquote obesity, all the same health issues that fat people get, thin people also get. So there’s complete overlap between symptomatology, there’s complete overlap between cardiometabolic profiles. It’s literally a body size. But when we say it’s a chronic disease, that means they can say, well, you just have to take our drugs forever.

[00:25:39] Ragen Chastain: And then the relapsing-remitting part is critical, because then when their drugs fail and people regain weight — even if they’re on the drugs — it’s not because the drugs don’t work, it’s because of the relapsing-remitting nature of the quote-unquote disease. And so this contextualization has been what is allowing them to build these billion-dollar profits. And another thing that they’ve done is to really systematically desensitize us to harming and killing fat people in attempts to make them thin. To the point that the FDA approval here in the States says that’s acceptable — the fact that these drugs have serious and sometimes fatal side effects is acceptable for the use of weight loss, just to make body sizes smaller. There’s no guarantee any health is gonna come from that.

[00:27:05] Ragen Chastain: And in the secondary use studies, where we look at kidney function or cardiovascular, consistently, it’s a small effect, but also, the effect happens before weight loss or without much weight loss. And so, even though they’re sort of glossing over that, because they want us to believe that if you lose weight, then health benefits follow — when in fact, it’s more likely that behavior changes create health benefits, and the weight loss is short-term and small.

[00:28:18] Stephanie: So, when we are looking at weight loss, short-term result, an average of 15-20%, the reason the pharmaceutical company explains for why people regain the weight is because of the relapsing nature of the disease.

[00:28:10] Ragen Chastain: Sure, so this becomes kind of a hilarious dance that you see. We’ve known for decades — 100 years of research looking, you know, Stunkard looked at it in 1959 and looked at the previous 30 years of research from the 1920s — that the vast majority of people lose weight short-term and gain it back long-term. And for a long time, the weight loss industry was able to use weight stigma to blame the victims of their interventions. It wasn’t people failing, it was the interventions failing. And I know that because they failed 95% of the time. There’s no medication that we tell people to take, and we’re like, well, if it fails, that’s on you. That’s not how these healthcare interventions work.

[00:29:06] Ragen Chastain: But then with the advent of these GLP-1s, and the idea of, well, we can say it’s a disease and it’s a relapsing, remitting disease, then they were able to shift, and that’s when they started the co-option of the idea of weight stigma. And so they’ve been working really hard to speak over and for actual fat-positive anti-weight stigma researchers to say that the definition of weight stigma is only fat people being treated badly, and fat people not having access to their drugs. And so we hear this idea of, basically, we don’t want to treat fat people badly, but we absolutely want to eradicate them from the earth and prevent any more from existing, but in a totally non-stigmatizing way, which is ridiculous. Obviously, you can’t do that. You can’t want to eradicate a way of being and then say, but we don’t want to stigmatize that way of being.

[00:29:57] Ragen Chastain: And everyone should go read Dr. Rachel Fox’s anti-obesity assemblage dissertation. It’s incredible in its understanding of how large this actual mechanism for eradicating fatness is. So you’ve got that. But they can’t really say, yeah, we’ve been lying to you all these years, and behavior-based interventions don’t work. So they, in all of the studies, say behavior-based interventions are the cornerstone of weight loss. However, they’re difficult to maintain. Well then, why are they the cornerstone of weight loss? What are you even talking about?

[00:32:27] Stephanie: The next piece that’s starting to really arise in the last 6 to 12 months is the claim of medical use beyond type 2: heart condition, Alzheimer’s, PCOS. Where is the state of the science on medical use beyond type 2?

[00:33:02] Ragen Chastain: Yeah, so it’s pretty shaky. One of the things that they’ve done — and you have to understand that we’re talking about endlessly deep pockets — so I’m involved in co-authoring 12 different studies now, and none of them are funded at all. We’re all doing this in our free time for no money. Whereas these drug companies have all the money in the world. And you’ll see researchers where they’ve taken millions of dollars from the drug company. And so that conflict of interest thing is a whole other issue. But in general, when they do a study for something specific, then we’ll see them do a ton of what are called secondary endpoints. So they’re like, we want to see how much weight is lost, but then we’re gonna test 50, 75 other things. And we’re not testing them for multiplicity, and we’re not calculating statistics appropriately — we’re just curious. But what they’re doing is creating this mystique.

[00:34:24] Ragen Chastain: So then they can look at all their data, and they can say what group of people is likely to have the greatest effect. Then they create a trial. And so that’s why we’re getting these trial populations that are really specific, but then they claim results for a very broad group. For example, the semaglutide cardiovascular trial: all they included were people who had to be 45 and older, you had to have pre-existing heart disease, and you had to have a body mass index of 27 or higher. And then they said their results applied to adults with quote-unquote overweight and obesity.

[00:36:10] Ragen Chastain: The cardiovascular trial was only statistically significant for white and Asian men as a composite. Average age of 61.6. It was not statistically significant for women, Black people, Hispanic people, those under 55 or over 75, or those with a BMI over 35. And so — but it got approved for adults. And the way that the study happened and the approval that they got, there’s a mismatch there. And the way that they did it is, I would say, diabolical — to put out that press release, to get a ton of press coverage. Novo Nordisk’s stock went up, I think, 16 or 17% that day. And then months later, they release the study, and we can all look at it. And they keep claiming the 20% benefit, but really, the absolute risk reduction is 1.5%. That’s what you can expect in the real world.

[00:38:07] Ragen Chastain: So, we see an effect, but the question that needs to be asked is: is this effect better than the drugs we have for this? And the Alzheimer’s thing, I think, is there’s a lot more research that would need to be done. Right at this point, it’s very unsure. And there’s no research on microdosing, so people who are microdosing — this is not FDA approved. It’s something that can happen in the U.S. because of our compounding pharmacy situation. So when these drugs came out, they went into an almost immediate shortage, and when there’s a shortage, compounding pharmacies are allowed to get involved. And typically, what compounding pharmacies do is they switch a drug’s method of delivery to work for someone. When the shortage happened, they were able to start producing and selling semaglutide and tirzepatide. That’s where the microdosing comes from — it gets around an FDA loophole. And it may be, as a harm reduction tool, that people not taking 2.4 or 7.2 milligrams may experience less harm from the side effects, but we don’t know anything about it. It’s not a research practice.

[00:39:54] Stephanie: So to sum this up — FDA approved is for type 2 diabetes, heart condition, and weight loss. Beyond that, none approved, none enough evidence for any other health condition as of May the 15th.

[00:40:07] Ragen Chastain: That’s my understanding. And I’m more of an expert in the U.S. system, so I won’t speak for other systems. But off-label prescription is allowed. Once a medication is FDA approved, a doctor has discretion, and there are important reasons for that. But with these, what I’m hearing from doctors and from patients who talk to doctors is that doctors are saying, oh, no, just get on a GLP-1, because they’re good for everything, they do everything. And that’s not true. That is a result of the marketing that the drug companies have done. And not just generally — they’re very specifically training doctors. The New Jersey arm of Novo Nordisk paid out not only well over $25 million in 2024, but almost 500,000 individual payments. So they’re doing a lot of training. There’s a database called Open Payments — if you go there, you can see what money a U.S.-based doctor has taken from the pharmaceutical and medical device industry. If you see food and beverage, that means they’ve been trained by the drug company.

[00:42:09] Ragen Chastain: They’re combining these playbooks of what the weight loss industry learned, what they learned from price gouging insulin, and then what they learned from Purdue Pharma and how they got OxyContin to be this blockbuster drug. And they’re taking all of that and then elevating it.

[00:44:58] Ragen Chastain: These drugs work both mechanically and psychologically to create weight loss. They slow gut motility, and in the case of tirzepatide, they reduce stomach acid. So food just kind of stays around longer. But psychologically, they cross the blood-brain barrier, and they manipulate and interrupt normal hunger signals. And another thing that they’ve rebranded is the idea of quote-unquote food noise, which is either normal hunger, or — and there are people who do have these persistent food thoughts, and that is a thing — but often, what we learn is that food noise can be solved with food. It’s a symptom of restriction, and sometimes lifelong restriction and weight cycling. But in general, people, especially fat people, are taught that if we are hungry, we’re wrong. If we want to eat, we’re wrong. And so if you get a medicine that turns that off, it can feel like a miracle. The problem is, one, your body’s still hungry, your body still uses food to live and do all the things it does. And you’re manipulating a survival signal. A hunger signal isn’t just happy fun times, it’s how we stay alive.

[00:46:28] Ragen Chastain: And so we don’t know how much it manipulates other signals. I’ve heard anecdotally from 6 or 7 physicians who’ve said, oh yeah, it’s been a big problem that my patients just don’t drink water anymore because they don’t think about it. And so people aren’t really getting ethically consented into this. Like, we don’t know how this is gonna impact your brain. And when you see people going on and off — either there’s people who are like, I use it for quote-unquote maintenance, so when I start to gain weight, I go on it — we don’t have evidence for what that does to the body. These drugs are typically titrated up, so you start at what’s known as a sub-therapeutic dose. This is just to get your body used to the drug. So when people are going on and off and they’re kind of doing it on their own, are they going on and off the highest dose? Are they re-titrating? We don’t know what they’re doing. We don’t understand the effects of that, and so there’s a lot of individual experimentation going on right now, and it, to me, is really concerning.

[00:49:15] Ragen Chastain: There are more deaths, hundreds more deaths for each semaglutide and tirzepatide than there were for Fen-phen. The reason I use the FAERS database is because it’s kind of an apples-to-apples comparison. There are limitations to this database, including that it can’t determine causality. Drug companies are required to report to it. Doctors and patients can report to it. My point was, look — when Fen-phen went off the market, there were so many fewer deaths than what we see now, and there’s no red flag or alarms raised. And so my point about it was that we’ve really, again, desensitized ourselves to the possibility that fat people are being harmed and killed in attempts to become thin. Also, FAERS only includes the brand name drug, so it won’t include any of these people who are on compounded drugs who had issues.

[00:50:21] Ragen Chastain: And Novo Nordisk was just essentially spanked by the FDA for systematically under-reporting serious side effects and deaths. They said it was concerning for their entire body of products that they were not capable of accurately assessing and meeting their legal requirement to report these adverse events. So you can go — it’s FAERS, the FDA Adverse Event Reporting System — you can go and look up any drug and see how many total side effects, how many serious, and how many deaths. And you can see with these drugs, exponential increases in serious side effects and deaths after the weight loss dose was approved.

[00:54:21] Stephanie: For the group of health practitioners listening to this — what would be your recommendation in regards to managing the flow between the marketing, headlines, and the actual science?

[00:54:21] Ragen Chastain: So, my first piece of advice is that you absolutely cannot trust the abstract, the results, or the conclusions of the study to tell the true story of the data. The longest study we have so far for weight loss is 4 years. It’s a study of semaglutide. The abstract, the results, the conclusions all said that weight loss was sustained for 4 years. They all left out the fact that they lost 89.5% of the trial participants over those 4 years. You cannot trust — and that’s hard because, one, you should be able to, and two, you don’t have the time to be digging into and analyzing studies. So finding sources that you can trust who aren’t the drug companies, questioning these ideas of, oh, these drugs do everything, asking the question, how does this compare to the drug that I currently prescribe for this health condition? Rather than saying, yeah, it might have a small effect on blood pressure, but maybe not even as much as lisinopril. And you’re talking about a very different profile of adverse events. So, asking those questions, just remaining constantly skeptical, and not taking training from the drug companies. They are very good at what they do. And it is a huge problem because their training is not giving anything close to the full picture of what’s actually happening here.

[00:57:41] Stephanie: Now, for a general population — would the recommendation differ, and if so, how?

[00:57:41] Ragen Chastain: So for general population, it’s sort of the same question. If they’re saying, we want to bring your blood pressure down, you go, okay, well, what are the other options for that? I really want to have a full informed consent conversation here. And when you say, like, alright, I want to have a full informed consent conversation, there can be a bit of a sigh, because they thought you were going to say, yes, GLP-1s. But they think they’re doing a good thing in most cases — there’s a lot of miseducation going on. In any time that somebody’s trying to prescribe weight loss to me, my question is, what would you do for a thin person who came here with this issue? And that sort of gets around it. And I will just say, I’m actually not interested in weight loss. I want to look at this from a weight-neutral perspective, so I want to support my health directly.

[00:59:29] Ragen Chastain: If you are on a GLP-1 for a health benefit — including type 2 diabetes or any other health benefit — you want to dose and titrate per that marker. So if you’re on it for blood pressure, you want to dose and titrate for blood pressure. And you want to say, what effect should I expect here? Is it 3 on the top and 2 on the bottom? What is the average? And if the provider doesn’t know that, then maybe let’s use a drug the provider does know, or let’s ask for more information. Because they’re just being told these are good for everything. So dose and titrate for the actual health issue. Don’t just allow relentless up-titration. If they’re trying it for weight loss, ask what they would do for a thin patient with this health issue. And ask for weight-inclusive care. And then ask, if they’re trying to put you on it for a health benefit other than type 2 diabetes, how does this compare to other drugs for this health issue, both in terms of benefit and the adverse event risk profile?

[01:01:11] Stephanie: I’m gonna put in the informed consent. I know you’re working on the document from the weight-inclusive medical students that produced in 2023 an informed consent in lay language for patients. You’re working on an updated version with the same group of people.

[01:01:18] Ragen Chastain: They’re working on it. I’m advising, but it’s really their document. Look for that updated version, because it’s gonna have more about the current research, the current dosing, the idea of these other health benefits that they keep trying to slide in for. But currently, the current version is still something that can be really helpful.

[01:02:02] Stephanie: What do you see our future being in the weight-neutral space in 5 years from now?

[01:02:02] Ragen Chastain: I think it has to be two things. We have to absolutely, unyieldingly hold the line on weight stigma. Any conceptualization of weight stigma has to include poor treatment of fat people, implicit and explicit bias, and any attempt to prevent, reduce, or eradicate fatness. Weight stigma isn’t bad because it might make people less likely to diet. Weight stigma is not the lack of access to weight loss drugs. Weight stigma is the poor treatment of fat people, including the attempt to prevent, reduce, or eradicate our existence. So we’ve got to hold the line on that, because they’re pushing so hard. And then the second needs to be an absolute right to weight-inclusive care.

[01:03:25] Ragen Chastain: Weight-inclusive health is an evidence-based ethical paradigm, period. It doesn’t matter what you think about weight, or if you think people can become thinner. And finally, the thing that I always say is that fat people have a right to exist without shame, stigma, bullying, or oppression. It does not matter why they’re fat. It doesn’t matter if there are health impacts of being fat, it doesn’t matter if they could or even want to become thin. Fat people have a right to full inclusion and accommodation in the world, including healthcare, period. And so I think we’ve gotta keep that in mind as we push forward in the next 5 years. It doesn’t matter if people can lose weight on these drugs, it matters that they have an absolute right to weight-inclusive care. And that that is an ethical, evidence-based paradigm that likely has more benefits with fewer risks.

[01:04:33] Ragen Chastain: Weight and Healthcare is my Substack. Sized for Success — S-I-Z-E-D for Success — is my speaker site. I speak all the time: CME, Grand Rounds, Lunch and Learns, for lay groups and for healthcare provider groups. Please reach out if that’s helpful to you. And Ragen Chastain on Instagram.

[01:04:59] Stephanie: Thank you very much for having taken the time to share with us. We’re likely going to do an update in a year from now to see what has changed in the science, because it rapidly changes. Thank you very much.

[01:05:07] Ragen Chastain: Anytime. Thank you for having me, and thanks for the work that you do here.