Glp-1 medications: Not quite a magic bullet for weight loss

Notes from the Heart by Fernando Riveron MD

Editor’s note: When Dr. Fernando Riveron reached out to ask about writing a column, I was thrilled. What a great way to promote health in the community and what a great addition to the publication!

Many of my readers probably know Dr. Riveron, but he is a retired heart surgeon at Aspirus and also one of the developers of the RiverLife Apartments along the Wisconsin River downtown. And he still travels to perform some heart surgeries, despite his retirement.

Today I am pleased to present the first installment of Notes from the Heart, a series of columns right here on The Wausonian. Please give a warm welcome to our new columnist Dr. Riveron!

Everyone is buzzing about the new wonder drugs -the GLP-1 inhibitors such as Ozempic, Wegovy, and Mounjaro - the ones making celebrities shrink and endocrinologists fist-bump. They are being hailed as the Holy Grail of quick and easy weight loss, the miracle fix for diabetes and possibly the best thing to happen to the pharmaceutical industry since Viagra. But before we start writing odes to Semaglutide (the hormone that powers GLP-1s) let’s have a real talk about why these are not a panacea for all.

Yes, they work, but at a cost

GLP-1s do work. They make people lose a lot of weight by slowing gastric emptying and making you feel full earlier. They also work centrally in your brain as a satiety factor taking away your appetite. They improve sensitivity to insulin - the hormone that causes you to deposit fat decreasing the work of your pancreas. They essentially induce a state of starvation.

The problem is that not all weight loss is good weight loss. When you step on a scale and see the number dropping, you might assume that fat is melting away like butter in a hot pan. Not quite. It turns out as much as 50-70% of the weight loss is muscle and bone, not fat.

Muscle mass: use it or lose it

Muscle is more metabolically active than fat; it is metabolic gold. The more muscle mass you have, the higher your metabolic set point. Lose too much and you slow your metabolic rate making long-term weight loss and maintenance harder. Muscle is our source of strength, power, and balance. Studies show the detrimental effects of sarcopenia (muscle loss) and subsequent frailty in our old age even impacting our longevity. We are more aware of the long-term effects of bone loss and osteoporosis which are associated side effects of these drugs.

Your heart is a muscle and it is not immune

Less discussed is the effect of GLP-1-induced weight loss on the myocardium. The heart is muscle and rapid weight loss can lead to changes in cardiac structure (remodeling) in ways we don’t fully understand. Studies suggest that GLP-1s may contribute to the loss of heart muscle mass, particularly in people with pre-existing cardiovascular disease or those losing weight too fast. Past studies have shown the effect of starvation on the heart leading to progressive cardiomyopathy (as in Anorexia Nervosa).

Although some large studies (such as SELECT) show cardiovascular benefits with fewer heart attacks and better glucose control, these tend to focus predominantly on patients with obesity and diabetes. These patients have an urgent medical need for weight loss. The generally healthy person using these drugs for easy weight loss is in a different group altogether.

The rebound effect is real

You take GLP-1s and rapidly lose weight; then what happens? For the majority of patients unless they choose to drastically change their diet and exercise patterns - the weight comes back fast. Your body is in starvation mode, and the hormonal forces that have suppressed your appetite come back with a vengeance. Your metabolism, dampened by muscle loss is set for weight gain.

Regaining weight without a specific focus on increasing muscle with resistance training and exercise means the weight more likely comes back as fat not muscle and certainly not as increased bone density. More fat deposition does nothing to help your heart or your diabetes. Studies suggest that patients regain as much as two-thirds of the weight they had lost within a year. So are GLP-1s a lifetime commitment?

The cost is real

Ozempic costs approximately $968.52 per month. Wegovy is $1,349 per month. Insurance may or may not cover some of the cost depending on medical necessity but patients are often on the hook for all or some. Consider the potential cost to our health care system if we extend this care to the estimated 50-70% of the American public that is overweight or obese.

So, are these Miracle drugs?

Without question, for people with diabetes, obesity, metabolic syndrome, or heart disease, these remarkable drugs can be life-changing. But for those looking for an easy way to undo a lifetime of bad habits, it’s not so simple. Sustainable health still comes down to exercise (muscle preservation), movement and healthy food choices. If you are considering GLP-1s, think about a strategy to protect your muscle mass through strength training, adequate protein intake and careful weight management. Perhaps most importantly develop a strategy to change the root causes of your weight gain through behavioral changes, food choices and exercise.

At the end of the day, a smaller body is not necessarily a healthier one. Our bodies are amazing machines and we need to maintain them with love and care.

---

Read next: