Greetings and welcome to the continuing chronicles of this geriatric wunderkind’s travails treating his Type 2 diabetes with Mounjaro. Here, laced with my firsthand experiences, I give you the sweet lowdown on diabetes drugs, their weight loss cousins, and the healthcare industry. My opinions are — well, you know what they say about opinions.
For the uninitiated, Mounjaro is one of a class of incretin drugs called GLP-1 receptor agonists that started out as diabetes treatment but later became the darlings of the weight loss industry. Once studies and anecdotal experiences established the weight loss possibilities of GLP-1 RAs, drug manufacturers quickly obtained approval to ply their wares to the weight loss community. Mounjaro (generic: tirzepatide) was relabeled as Zepbound, Ozempic (semaglutide) became Wegovy, and Victoza (liraglutide) became Saxenda.
GLP-1 RAs have benefited many people, but in their euphoria, proponents, particularly in the weight loss industry, tend to downplay their risks. The prospect of easy, painless, automatic weight loss is too big a carrot not to take down in one big gulp. Unfortunately, unless accompanied by stringent dietary and strength training, that weight loss will be partially lean tissue — muscle. And, let’s face it— if people have failed at dieting and exercise programs in the past, they are seeking weight loss without the necessary demanding work.
That leads into this week’s two stories. One is about yet another expensive complimentary drug to stem the muscle loss associated with GLP-1 RA weight loss, a potentially costly boon for those looking for miracles. The other is a sell-out to Big Pharma by doctors who prefer drugs over lifestyle modifications as front-line treatment for obesity. Behold, a two-way winning week for Big Pharma!
The Two-Edged Syringe: Saving Muscle, Selling Out
Your weekly purveyor of metabolic mayhem returns with a double shot of GLP-1-related developments—one that might actually help people keep muscle while losing weight, and another that suggests the American College of Cardiology has finally been fully absorbed by the Big Pharma Borg.
Let’s start with the encouraging news. A recent phase 2 study suggests that semaglutide, when paired with the biologic bimagrumab, can preserve lean muscle mass during weight loss. That’s right: you get the fat loss benefits of a GLP-1 agonist without your thighs disappearing faster than a 401(k) in a bear market. In the trial, the combination led to a 15.6% reduction in body fat but actually increased lean mass by 1.5%. Compare that to semaglutide alone, which dropped fat by 8.6% but took 4.9% of muscle with it—like tossing out the baby with the bathwater, if the baby were your quadriceps.
Now, before we pop the champagne and start pricing out new belt sizes, there’s a big pharma-sized catch: cost. Bimagrumab is a monoclonal antibody, which means it doesn’t come cheap. Think “second mortgage” tier, not “skip Starbucks” tier. It’s also still experimental, so you won’t be getting this dynamic duo at your local CVS any time soon—unless your insurance plan has recently adopted a policy of underwriting miracles.
Snatching Victory from the Jaws of Defeat (with drugs)
While one hand gives (maybe), the other hand takes. Or in this case, shovels. This week, the American College of Cardiology issued new guidance that would allow physicians to initiate pharmacologic therapy for obesity without requiring patients to fail lifestyle interventions first. On the surface, this seems compassionate—why wait for people to suffer the futile shame spiral of diet failure when we have effective medications?
Yet scratch that surface and you hit gold—gold coins, that is. The ACC’s endorsement reads less like clinical guidance and more like a press release jointly issued by Eli Lilly and Novo Nordisk. By removing the need for a lifestyle “try-and-fail” period, they effectively convert every overweight adult into a potential subscriber to a lifelong, extremely expensive prescription plan. It’s a win for stockholders, not necessarily for patients—or for society, which now must reconcile the idea of drug-first treatment for a condition that remains deeply behavioral and environmental.
Let’s Fudge a Diagnosis
But the guidance doesn’t stop at endorsing first-line pharmacotherapy. It also tiptoes up to a truly uncomfortable ethical line. The document suggests that when insurance balks at covering GLP-1s for “just obesity,” clinicians might consider whether a diagnosis of prediabetes or type 2 diabetes could be used to meet coverage requirements. In plain English: if the BMI won’t get your patient the drug, go fishing for a glucose-related diagnosis code that will.
This kind of chart-padding may be common in modern medicine, but let’s not pretend it’s benign. It risks turning real diseases like Type 2 diabetes into mere leverage for insurance billing—a perversion of clinical diagnosis into a transactional code game. It also muddies the waters for those of us who have diabetes, who already navigate enough bureaucratic skepticism about whether we “really need” these drugs.
If Big Pharma’s marketing department had slipped this into a slide deck at a sales meeting, we’d all roll our eyes. That it comes from the American College of Cardiology in a formal position document should provoke outrage.
The Bottom Line
So what’s the net effect? You can preserve muscle now—maybe—if you can afford a biotech-grade add-on. And if you’re a doc, you no longer must waste time advising diet and exercise before hitting the GLP-1 easy button. It’s all very convenient. For everyone except the patient paying $1,200 a month for the privilege of being slightly less obese, with slightly less muscle.
I’ve spent 56 weeks harping on the dangers of muscle loss during GLP-1-mediated weight loss. This bimagrumab news is a legitimate scientific advance. But the rush to put everyone on injectables—without even a speed bump labeled “behavioral change”—feels like a cynical shortcut. It’s hard to view it as anything but a declaration of defeat on the lifestyle front. Or maybe just a good quarter for Novo.
My Week on Mounjaro
I continued physical therapy for my “good” knee. Monday’s session was a “come to Jesus” conference with the therapist, where I reviewed the treatment plan, noting several aspects she was failing to provide. So, naturally, my second visit that week was a torture session. Be careful what you ask for!
The only other medical encounter during the week was an always pleasant visit to my podiatrist. She runs a small, family practice, a legacy of her dad, who is a respected, semi-retired podiatrist in this area. Many of the other podiatric practices have been swallowed up in the great private equity healthcare consolidation, which drives a wedge between patients and physicians, so it is refreshing to find a friendly practice where patients are treated like family.
But I digress. Let’s move on to the numbers for the week.
- Weight: 173.6 lbs — down 2.6 lbs.
- Fasting Glucose: 106 mg/dL — about the same.
- Stelo Overall Average: 105 mg/dL — down slightly.
See You Next Week
That’s all for this week from your favorite Type 2 cyborg. Muscle matters. Ethics matter. And if the ACC needs help rewriting their next press release, I hear Novo’s hiring.
See you next week—syringe in hand, dumbbells at the ready, and moral compass (mostly) intact.
For an annotated catalog of all my Mounjaro updates, please visit my Mounjaro Update Catalog page.
