Peptide Purgatory: Do You Qualify for a GLP-1?

We have a new look here! My tired old 2014 theme was beginning to annoy me, so I opted for something more readable. If you find anything broken or deficient, please let me know.

In this week’s issue, we present yet another example of ostensibly scientific literature aimed at expanding the GLP-1 receptor agonist market. Yeah, I know — ho hum — a recurrent theme here. I’m not beating a dead horse; I’m grinding it up and making horse meat. But mark my words: by the end of the decade, you’ll be able to buy these drugs at the local 7-11.

In addition to taking the proverbial piss on Big Pharma, a regular occurrence around here, I’ll be supplying an update regarding my personal health progress and my most recent visit with young Dr. Macallan, my fresh-faced direct primary care physician who replaced the legendary overpriced pseudo-concierge doc, Dr. DeLorean. (For those new to The Nittany Turkey, those are not their real names).

GLP-1 Market Now 800,000,000 People

The latest offering from The Lancet Diabetes & Endocrinology performs a neat little trick: it dresses up market sizing as global health policy and calls it epidemiology. By the authors’ own math, more than one in four adults worldwide—roughly 800 million people—now “qualify” for GLP-1 receptor agonists. Instead of a treatment guideline, consider this a PowerPoint slide for an earnings call for Novo Nordisk or Eli Lilly.

The eligibility criteria are familiar, almost comforting in their simplicity: BMI >= 30, or BMI >= 27 with hypertension or diabetes. Expand that slightly for Asia, stir in pooled surveys from 99 countries, and voilà—an addressable market so vast it would make a tobacco executive blush. One almost expects a footnote reading “numbers may vary depending on quarterly guidance.”

Injectable Drugs First, Common Sense Later

What is striking is not that obesity is prevalent. We already knew that. What is striking is how seamlessly the scientific community now accepts the premise that pharmacologic intervention at population scale is the default response, while upstream causes—food policy, agricultural subsidies, urban design, and the relentless industrialization of calories—are relegated to the final paragraph as a sort of moral appendix. Yes, the paper dutifully nods to “multilevel agricultural and food policies,” but only after the damage has been fully monetized.

The scale of potential eligibility for GLP-1 receptor agonists, combined with their high costs, demands strategic, tailored policies and programmes to integrate GLP-1 receptor agonists in routine care.

Government agencies, for their part, are portrayed not as regulators but as enthusiastic integrators—creating guidelines and exploring policies to fold lifelong injectable therapy into routine care. Translation: public payers are being prepped to underwrite what marketing departments have already normalized. When WHO is name-checked in the opening section, you can practically hear the cash registers warming up. Ka-ching!

Obesity: A Chronic, Relapsing Disease

And let us not pretend this is happening in a vacuum. Eli Lilly and Novo Nordisk did not merely stumble into this moment through plucky Scandinavian innovation. They cultivated it—through trials, advocacy, disease re-definition, and a careful reframing of obesity from a societal failure to an individual pharmacologic deficiency. The scientific literature, increasingly populated by eligibility studies like this one, provides the intellectual scaffolding. The state provides the reimbursement. The companies provide the pens.

None of this means GLP-1 drugs are ineffective. They are, by most measures, remarkably effective. But when a quarter of the adult human population is suddenly “eligible” for a branded injectable therapy, the correct response is not applause. It is skepticism. Medicine is supposed to treat disease, not declare most of humanity suboptimally medicated.

If this is the future of public health—identify a widespread condition, redefine the threshold, publish a global count, and hand the invoice to governments—then we should at least stop pretending this is accidental. It is a business model. And judging by the numbers, it is a very good one.

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My Week on Mounjaro: Annual Physical (Sort Of)

Dr. Macallan runs a direct primary care practice. For those unfamiliar with the direct primary care model, this is a recent workaround for the health insurance morass. Direct primary care docs work outside the bounds of private and government health insurance, charging a fixed monthly fee in exchange for unhurried office visits, communication outside office hours, and other benefits such as maintenance drugs at no charge and reduced fees for lab diagnostics.

My forty-five minute follow-up visit with Dr. Macallan was efficient and productive. Blood work and imaging ordered. Prescriptions discussed. Recommendations made. All in a genial, collaborative mode.

What distinguishes a productive visit from the usual medical charade is not speed, but signal-to-noise ratio. This one had a high signal. We worked through a prioritized list rather than ricocheting between whatever happened to scroll into the electronic chart that morning. The lung nodule, iron status, kidney function, gout, and surveillance imaging were all addressed explicitly, not waved away with the clinical equivalent of “we’ll keep an eye on it.”

That alone puts Dr. Macallan several standard deviations to the right of the mean.

Ironic, Isn’t It?

Iron was the one area where we politely disagreed. My ferritin is now comfortably normal after IV Venofer in the fall, my hemoglobin sits at a respectable 14.7, and iron saturation—long my trouble spot—has finally climbed into the high-20s. From his perspective, that’s case closed with twice-yearly monitoring. From mine, iron saturation remains the more sensitive canary in the coal mine, especially in the context of CKD and endurance hiking. We compromised in the adult way: data will decide. No sermonizing, no appeals to authority, just labs at defined intervals and reassessment if trends misbehave.

Chronic Gout

Gout, on the other hand, required less philosophical discussion and more mechanical clarity. Between the October flare, rat-bite erosions on X-ray, and a now-palpable tophus over the MTP joint, the diagnosis has matured from “annoying episodic guest” to “chronic housemate.” That moves urate-lowering therapy from optional to inevitable.

Where we did have a substantive exchange was dosing. The initial plan had me starting allopurinol at 300 mg daily, which may be expedient, but expedience is rarely my preferred design constraint at age 79 with stage 3 CKD. Package labeling and common sense both still recommend starting low and titrating upward in patients with reduced renal reserve. I made the case—calmly, with citations—that I was not interested in discovering idiosyncratic hypersensitivity syndromes the hard way.

To his credit, Dr. Macallan agreed immediately. The prescription was rewritten for 100 mg tablets so I can start at 50 mg daily and ramp up deliberately, with colchicine as flare prophylaxis during the transition. Slower? Yes. Safer? Also yes. I’ll trade speed for margin every time.

Imaging

CTA

Imaging required similar triage. A CTA (computed tomography angiogram — a fancy CT scan to observe coronary arteries) had been proposed as “routine CAD surveillance,” which is one of those phrases that sounds reassuring until you interrogate it. My last cardiac CT in late 2023 showed only mild, non-obstructive plaque—nothing that justifies contrast, radiation, and renal stress on a two-year cadence. When I asked the obvious question—what clinical question is the CTA meant to answer?—the answer turned out to be: none in particular. We postponed it until 2028, or sooner if symptoms develop, which is how evidence-based medicine is supposed to work.

Cancer Screening Lung CT Scan

The lung CT was more nuanced. A 3 mm incidental nodule, stable and explicitly labeled benign on a June 2025 scan, does not justify aggressive follow-up. Nor do I meet Medicare’s criteria for annual low-dose lung cancer screening: I’m too old, and I quit smoking in 1989, back when shoulder pads were still a thing. Bell-bottoms were out by then, but I digress. That said, I will self-pay for a single non-contrast diagnostic chest CT—$159 at Advent—purely to close the loop on my own terms. My choice there. CMS need not be involved.

Abdominal MRI

The MRI, finally, is the easy one: routine surveillance of known pancreatic IPMNs per GI recommendations, kidney-safe, contrast-free, and uncontroversial, a lasting legacy of my consultation with the Irascible Dr. Scrooge, my gastroenterologist.

Both scans are scheduled on January 26, a week from today.

Lab Results — Not Too Bad

The follow-up labs tell a reassuring story. Kidney function is stable, with no albuminuria. A1c sits at 5.5. Lipids are boring in the best possible way. The uric acid, oddly, remains at 4.1 mg/dL—low enough to confuse anyone who believes single lab values are Platonic truths. Between post-flare physiology, SGLT2-mediated uricosuria from dapagliflozin, and the well-known noise introduced by creatine supplementation, I’m not losing sleep over it. Crystals don’t dissolve because one blood draw had a good day.

Dr. Macallan’s comment about the uric acid level was, “You are already at the uric acid goal now so you could just stick with 50 mg allopurinol indefinitely for right now. And if it changes on future labs we have room to increase it.”

All told, this was not an “annual physical” so much as a systems check with intent. No drama, no heroics, no unnecessary scans ordered to appease an algorithm. Just a thoughtful, collaborative recalibration—exactly what direct primary care promises, and too rarely delivers.

Hernia Update

One loose end from late 2025 deserves closing, if only to reassure readers who assume that abdominal surgery at 79 consigns one to a lifetime of reclining furniture and elastic waistbands.

I am now six weeks out from a robotic mesh repair of a right inguinal hernia, and recovery continues exactly as advertised. At my two-week postoperative visit with my surgeon, Dr. O, in late December, the exam was entirely unremarkable: incisions healing cleanly, no evidence of recurrence, no infection, no complications worth a footnote. What discomfort existed then was described—accurately—as soreness rather than pain. That distinction has only sharpened with time.

Functionally, I’ve been walking , using the treadmill at the Y, and doing light dumbbell work with some pussy dumbbells at home. Bowel function normalized quickly with minimal pharmacologic persuasion. The brief and mildly disconcerting episode of postoperative testicular wanderlust resolved on its own, as these things usually do, without drama or intervention.

Minor Frustration

The only real frustration is one of restraint. I remain under weight restrictions for another couple of weeks—no deadlifts, no heavy benching, nothing that treats the core like an adversary rather than a collaborator. The surgeon’s guidance was explicit: cardio, running, cycling, stair work, swimming, and light resistance are fine; maximal effort lifting can resume at the end of January or early February.

That date is circled.

When the green light comes, I’ll ease back into the barbell work deliberately, not heroically. Deadlifts, presses, and squats will return, but they’ll do so under adult supervision—mine. The absence of pain, the stability of the repair, and the overall smoothness of recovery have done nothing to dampen my eagerness to get back under load. If anything, the enforced pause has sharpened it.

For those keeping score, this is what “successful surgery” looks like: no lingering symptoms, no chronic pain narrative, no cascade of follow-ups, and a clear path back to normal activity. Boring, in the best possible way.

Next week: living with allopurinol, watching urate like a hawk, planning my post-surgery workout routines, and continuing my ongoing experiment in aging without surrendering agency. Stay tuned.

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And that’s a wrap…

So where does that leave things this week?

On the personal front, the answer is mercifully boring. Metabolically steady. Renally stable. Iron finally behaving itself. Gout has crossed the Rubicon from episodic nuisance to managed chronic condition, with a plan that favors margin and method over macho dosing. Imaging has been trimmed back to what answers actual clinical questions rather than what placates algorithms. The hernia repair is holding exactly as engineered, and the only lingering annoyance is temporary prohibition from loading a barbell by professionals whose livelihoods depend on patients not doing anything spectacularly stupid.

Beating That Dead Horse Again

Layered on top of that mundane systems check was a familiar intellectual exercise: watching GLP-1 receptor agonists continue their steady evolution from useful metabolic tools into something closer to a secular sacrament. Obesity treatment, cardioprotection, cancer prevention, longevity—if you squint hard enough, these drugs now appear capable of absolving poor diet, bad sleep, and possibly original sin. What remains conspicuously scarce in much of this literature is proportionality: effect sizes in context, confounders treated seriously, and conflicts of interest examined as more than a box-checking exercise.

None of this negates the genuine utility of GLP-1s. I am, after all, still taking one. What it does underscore is the widening gap between measured benefit and marketing ambition—a gap increasingly filled by eligibility studies masquerading as policy guidance, breathless extrapolation, and a scientific establishment that seems oddly comfortable letting industry set the narrative tempo. That discomfort, more than the drugs themselves, is what keeps earning repeat visits to Bullshit Corner.

Keeping It Under Control

Taken together, this week wasn’t about breakthroughs. It was about boundary setting: knowing when to accept a drug, when to defer a scan, when to titrate slowly, and when to ask the most basic question in medicine—what problem are we actually trying to solve? Aging well is less about chasing every new promise and more about managing known risks without outsourcing judgment.

Next week: the allopurinol ramp, continued urate voyeurism, and a cautious return under the bar once surgical mesh is no longer the weakest link in the system. There will almost certainly be another GLP-1 miracle paper to read, annotate, and file under interesting, but calm down.

Until then: stay upright, stay skeptical, and remember—not too bad remains a vastly underrated clinical outcome.

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Peptide Purgatory chronicles one old fart’s ongoing experiment with GLP-1s, metabolism, and medical modernity. Side effects may include sarcasm, elevated skepticism, and mild tachycardia while reading policy papers. So, ask your doctor whether Peptide Purgatory is right for you!

For an annotated catalog of all my Peptide Purgatory and Mounjaro updates, visit my Mounjaro Update Catalog page.