I used to write GLP-1 prescriptions faster than I should have.
A patient would come in carrying extra weight and a folder of worry, and I had a drug that worked. It felt like help. Most of the time it was. But I was skipping past the question that actually matters. Not whether someone qualifies for semaglutide. Whether the weight is the whole story, or just the part that finally got measured.
There’s a patient I see often. Not one person. A composite of patients who walk through my door most weeks. She’s in her forties. She runs a household, half a career, and a calendar that never has a blank square. Her labs come back close enough to normal that her last doctor waved her through in eight minutes. Her A1c sits right at the edge. Her cholesterol is fine, mostly. Nothing flagged as urgent.
But she is tired in a way sleep does not touch. She has gained fifteen pounds in two years without eating any differently, or so she says, and I believe her. She stands in the checkout line at HEB some evenings, reading a label, wondering when her own body turned into someone else’s.
Good labs. Bad life. There’s a reason.
The reason usually doesn’t show up on a standard panel. It’s visceral adiposity building around organs a bathroom scale can’t see. It’s cortisol running high at eight at night instead of dropping the way it’s supposed to. It’s three hours of broken sleep nobody asked about, because the visit was built for eight minutes and a refill. A GLP-1 can genuinely help with some of that. It slows the stomach. It quiets a hunger signal that’s been shouting for years in some people. I’ve watched patients tear up in the first month, not because the scale moved yet, but because the noise in their head finally went quiet.
That relief is real. I don’t discount it.
What I won’t do is pretend the prescription is the whole treatment. Wellness culture has turned GLP-1s into either a miracle or a moral failure, depending on which corner of the internet you’re standing in that week. Neither version is honest. These are real medications with real tradeoffs. Muscle loss is the one nobody mentions at the med spa, and it matters if a patient isn’t also lifting something heavy and eating enough protein. A good number of people are getting these drugs through compounded sources with no long-term safety data behind that specific formulation. I say that plainly to every patient, semaglutide and tirzepatide included, whether I’m the one writing the script or not.
There’s a peptide gold rush running alongside the GLP-1 boom right now, and I watch patients arrive having already self-dosed something like BPC-157 from a supplement site with no physician anywhere in the loop. A few peptides have real, narrow uses. Most of what’s being sold has more marketing behind it than data. I say that too, even when it costs me the sale of something flashier than a conversation about sleep.
Here’s what I actually check before I write anything. Sleep, first, because almost nobody has been asked about it. Cortisol pattern, since a rhythm that’s supposed to fall in the evening and doesn’t will drive fat storage no diet fixes alone. Inflammatory markers like hsCRP, not just the lipid panel everyone’s used to seeing. Insulin resistance, which shows up years before a diabetes diagnosis if you know where to look. And sometimes grief, though patients rarely bring that word into a weight visit themselves. I had a patient last year whose weight climbed the same month her mother entered hospice. Nobody had connected those two facts before she sat down in my office. The medication helped her eat less. It did nothing for why her body had been holding on so hard, all on its own, for so long.
I see the same pattern in the executives I treat through our corporate wellness work. High performers, cortisol through the roof, sleep fragmented by a phone they won’t put down, autonomic dysregulation that a basic metabolic panel will never catch. GLP-1s get requested there too, usually as a fast fix for a body that’s been ignored for a decade in service of a career. The drug doesn’t know the difference between weight that came from genetics and weight that came from eighteen years of skipped lunches and stress eating in a parking lot before a board meeting. It just responds to the signal it’s given.
Medicine likes a fast answer. Wellness culture likes a shortcut dressed up as something sacred. I sit in the third space between those two most days, in the clinic and in everything else I write here. My job isn’t to defend the drug or condemn it. My job is to find out what’s actually going on in the specific body sitting across from me, and to say plainly when a prescription is treating a symptom instead of its cause. I made a version of this same argument about functional medicine without the hype, and I keep making it, at greater length, in the book I’m writing called Healing the Split.
It’s the same question underneath the longevity work I write about elsewhere, and the same one I bring into every visit at Prime Vitality Care. Versions of this argument have run on Medium too, if you want the longer thread.
I was wrong for a while about how much explaining this takes. I used to think a good clinical reason would land in one visit. It doesn’t, usually. It takes two or three conversations before a patient stops asking “will this make me thin” and starts asking “what has this weight been protecting me from.” That second question is the one that changes the visit.
The woman from the HEB line, the composite of everyone I’ve just described, still has labs that look fine on paper. Her life is getting a little louder again, slowly, in ways she can name now. The GLP-1 bought her some room to breathe.
What she does with that room is the part that actually matters.
Dr Shiv Kumar Goel is an internal medicine and functional medicine physician in San Antonio. Across 25 years in hospitals, intensive care, and functional medicine, he has studied the gap between what medicine can measure and what patients actually live through. He writes Healing the Split and is the author of the forthcoming book Healing the Split: When Your Biology Is Fighting Your Biography.