a note on semaglutide shots

can we even have a neutral convo about this?

it's hard to imagine something so polarizing ever being neutral. and, the experiences people have in their bodies are often far from neutral.

so, feel free to read on, or skip for another day or....never. i'm going to touch on what these medications are, my experience as a dietitian with the rise of weight loss medications, and some case studies.

i've worked with clients who have been prescribed and/or taking medications such as Wegovy, Ozempic, Mounjaro, and Phentermine, and Metformin. with industry shortages, pharmaceutical companies are working to find pill variations of these injectable medications. all this to say, these meds aren't going anywhere.

people assume a "weight neutral dietitian" means someone who would turn such clients away. personally, i believe everyone is deserving of the education and strategies needed to nourish their bodies. most of my clients desire weight loss in some capacity, even if they aren't pursuing it. It's something we talk about a lot.

if you want to part a sea of people, ask them how they feel about weight loss medications. the opinions can feel like dogma. folks in the fitness industry call them the "easy way out." some anti-diet providers are quick to call out off-label usage [fair, and also this is not unique to these medications]. others intend compassionately to say "you're enough!" while disregarding autonomy. it's messy.

you are enough and i fully get it if you've spent your life navigating weight stigma and discrimination. for many, occupying a smaller body means living a life that provides greater safety and access and less harm. we have to acknowledge the role of body privilege if we want to have a conversation about weight loss medications.

briefly, what do these medications do?

the active ingredient in Wegovy and Ozempic is semaglutide, which is categorized as a glucagon-like peptide-1 [GLP-1] receptor agonist.

did you know GLP-1 is a hormone you already have in your body? it tells your brain that you are no longer hungry, and it prompts your body to produce insulin to lower your blood sugar. pretty cool! this helps regulate our hunger and fullness.

by taking GLP-1 receptor agonists, you are introducing a medical intervention that revs those metabolic processes. GLP-1 receptor agonists will reduce the urge to eat [in the brain], decrease blood sugar [by telling the liver to decrease glucose production and the pancreas to increase insulin secretion], and elicits feelings of fullness [by slowing gastric emptying in the stomach].

in the case of Mounjaro which uses terzepatide, there is a dual action of GIP and GLP-1 receptor agonists. the main difference is that GIP, glucose-dependent insulinotropic peptide, both increases insulin secretion and also insulin sensitivity.

given these mechanisms of action, those who take these medications have significantly decreased appetites. i remind my clients often: weight loss medications do not lower your biological energy needs; they mask them.

the side effects of these medications in the short-term are fairly well-known: dizziness, nausea, vomiting, constipation, diarrhea, bloating, headaches, fatigue. the TikTok banter about Ozempic face, Ozempic finger, and Ozempic butt are physical outcomes folks experience with rapid weight loss and skin sagging. not everyone has side effects, and side effects may change over time for folks who take these medications.

we do not know the long-term side effects [that is, beyond a few years] of these medications yet! given that these are medications for the long-term, this is an essential factor to consider. there is an increased risk of thyroid tumors and pancreatitis when taken for 1-3 years. folks with a family history of medullary thyroid cancer are advised against taking these medications.

the bottom line on these medications is that they work because they interrupt your biology. there is a genetic component to our body weight and composition. these medications on their own do not change your set point, and they are not intended to be taken for short-term weight loss. they're a long-term choice.

to quote an article from Nature, "the idea that you could stop the medication and not have the weight regain is a non-biological idea, which doesn't make any sense."

so, let's talk about how this plays out in real life.

i will share a few anonymous case studies with you to help elucidate what it looks like to take these medications alongside living your full and busy life. i've named these folks after colors. after each case study, i'll offer a note of nuance.

Case 1: Blue was a referral to me from her therapist. She has occupied a larger body her entire life, struggled with binge eating disorder, and was working through a lot of the trauma she experienced growing up queer and bigger than her peers in the rural South. She was taking semaglutide before we met, and she feels the medications allow her brain to 'relax' around food and alcohol. we don't talk much about her weight loss because her goal with our work is to learn about nutrition, plan meals for herself, and start weightlifting. during a brief period of medication shortage, she named she could have eaten her entire pantry because of the return of her hunger pangs. she is planning to take this medication for life and often says it has given her a chance to practice healthy habits.

Note of Nuance: Blue is a client who shows up with questions and feedback. she is diligent about eating three meals/day with carbs and protein, and she loves playing with new recipes using seasonal produce. she was well-informed of the medication side effects and usage, and she stays in touch with her medical provider for appointments and labs.

Case 2: Yellow and I started working together early this year to create consistent eating habits. her friends asked her to complete a 3-month challenge at a medi-spa, which provides compounded semaglutide for 12 weeks. she wanted to "see what happens" after we discussed at length the mechanism of the medications, side effects, and risk for weight cycling. assessed by bioelectrical impedance analysis technology, Yellow lost ~7 pounds... of muscle mass. She was too fatigued to workout or go on walks, and she ate one meal a day. as lifelong athlete, Yellow was so disgruntled with her experience that she discontinued the meds.

Note of Nuance: Yellow has struggled with a changing body after decades of fitness and sport. she was able to come to terms on her own, through her experience and learning, that losing muscle and energy was not worth it for her as she enters menopause.

Case 3: Lavender is a chronic dieter who has struggled with a fear of processed carbs. her main goals are muscle gain and strength, though her body image has impeded her nutrition shifts. we discussed the importance of working toward food neutrality so she could feel stronger in her workouts. her friends were taking compounded semaglutide and saw results. Lavender discontinued sessions and picked up a few months later because the carb and body image struggles worsened. she met her weight loss goal, but she was embarrassed to wear tank tops and shorts due to the look of her arms and legs, which had lost muscle definition. she is afraid to discontinue the medication.

Note of Nuance: i think a lot of folks can resonate with Lavender. achieving a goal weight does not always yield an improved body image. both Yellow and Lavender are taking semaglutide from a compound pharmacy, which is legal due to the shortage of the medication. however, compounded variations are not assessed by the FDA for quality or safety. many compound pharmacies are ethical, however, there are pharmacies compounding semaglutide salts or combinations with B12, which have not been assessed for efficacy, safety, or contraindications.

Case 4: Teal is a proud sturdy girl who lifts weights 3-4x/week. she works a busy job and has experienced weight gain alongside a stressful career, struggles with sleep, and a recent PCOS diagnosis. she was prescribed Metformin by her doctor for "insulin resistance" even though she had a normal A1c and fasting glucose. after a few months of GI distress, she discontinued the medication. she is recommended GLP-1 receptor agonists by friends, family, and medical providers often. she is overwhelmed by the idea that her fitness routine may be impeded by even more fatigue than what she currently experiences.

Note of Nuance: Teal is right there with you. the recommendations just keep coming, and she is so tired of it. she is watching her friends lose weight quickly. we talk often about the importance of consent and autonomy, and that she is able to decide what is right for her body - even if no one else 'gets it' or understands why she wouldn't pursue the medications.

Case 5: Peach is a peach! we work together to create consistent eating routines with her ADHD. she was ashamed about taking Mounjaro and noticed the world "opened up" for her when she started losing weight. she struggles with fatigue, but otherwise, she has no other side effects. her doctor directed her to discontinue the medication when she hit her "goal weight," but she is at a crossroads. she is treated so differently now and receives a lot of compliments for her weight loss, which feels "like a Catch-22." however, the fear of weight regain is so prominent in her brain. she is now working with her provider and a therapist to address next steps.

Note of Nuance: i really feel for Peach because of the shame wrapped up in taking the medication and the anxiety around what will change in her life when she stops taking it. she is experiencing one of the most painful attributes of diet culture, which is that idolizing thinness really hurts everyone.

Looking back over this piece, I do feel sort of neutral about these medications. perhaps because I feel like I have to? they are here now, and they are here to stay for the foreseeable future. i refuse to make clients past, present, or future feel judged for decisions to consider, take, or discontinue medications. i do have reservations and concerns about what happens throughout the next decade as these medications become more and more common.

i don't feel like they "take the place of my job" because, again, people deserve to be educated about nutrition and supported in nourishing their body throughout their lives. and, I want you to see that these medications are more than "weight loss miracles." there is so much nuance left unsaid in a before and after photo, and I hope these case studies helped elucidate some nuance for you.

in my experience as a private practice dietitian, i do see folks before, during, and after trialing a weight loss medications. if there is one thing I can see clear as day, it is this:

there is no set amount of weight loss that transports us to that "promised land" of body love and appreciation. there is no medication addressing the system failures that prevent folks from accessible nutrition, wellness, and medical care.

your body, in any and all sizes it may occupy, does not need to earn food.

you require it.

your existence necessitates nourishment.

and, to me, that is a beautiful opportunity to show up for yourself each and every day.