The First Four Weeks, Without the Filter

I promised I would write this before the memory smoothed over. So these are largely notes taken in the moment, lightly tidied, in the order they happened.

Week one: the anticlimax

The injection itself is a non-event. I have given thousands of them and received a fair number and this one is genuinely at the low end — a fine needle, a click, four seconds, into the abdomen. My hands were unsteady, which had nothing to do with the difficulty of the task.

The starting dose is not a therapeutic dose. It is 0.25 mg, and its job is to introduce your gut to the concept. I knew this. I had explained it to patients dozens of times: don’t expect anything for the first month, we’re just getting your body used to it.

I still spent the first four days paying close attention, as though something ought to be happening.

Then on day five, at about four in the afternoon, I noticed I had not eaten lunch.

Not skipped lunch, in the grim white-knuckled way I know well. Not thought about it. The reminder that normally arrives around 12:30 and then again with increasing urgency until it is answered simply had not arrived.

I sat in my office and had an unexpectedly emotional few minutes about it.

The part I did not anticipate

I have been describing “food noise” to patients for two years. I understood it as a clinical phenomenon — reduced hedonic drive, altered reward processing, a well-described effect on cravings.

What I had not understood is how much cognitive real estate it had been occupying, because you cannot perceive a background process until it stops. I had somewhere between six and ten small negotiations happening every day — what’s for dinner, is there anything in the drawer, should I eat now or wait, I shouldn’t have had that, I’ll be better tomorrow — and they were so constant that I had no idea they were separate from thinking.

When they stopped, the quiet was disorienting. It was, for about a week, genuinely destabilising.

I had assumed that noise was me. It turned out to be a signal, and it had a volume knob, and someone else had been holding it this whole time.

I am aware of how that sounds. I am aware it is exactly the sentence that appears in the marketing. I can only tell you that I was actively braced against having that experience — I am constitutionally suspicious of anything I have heard too many patients say — and I had it anyway.

The grief part, which nobody mentions

Somewhere in week two I made dinner for friends. I cooked something I love. I had about a third of what I would normally have and I was pleasantly, completely full.

And I felt a small, sharp, unmistakable sadness.

I want to be careful about this because it is easily misread. It was not regret. It was something more like: one of my genuine, uncomplicated pleasures had just been quietly turned down, along with the compulsive part, and the drug does not distinguish between the two. Food is not only a fuelling problem for me. It is how I host people, how I mark occasions, how I love my family. Some of that got dimmer.

It came back, mostly, by about week five as I stabilised. But I have thought since about how many patients must have that feeling and never say it, because the expected script is gratitude, and because saying I miss eating out loud sounds ungrateful and slightly unwell.

It is neither. It is a reasonable response to losing something real, alongside gaining something real. Both can be true. Nobody put it in the pamphlet.

The physical stuff, honestly

Nausea: present, mild, for about 36 hours after each of the first three injections. It responded to exactly what I tell patients: smaller meals, less fat, stop eating before I felt done. Never once close to intolerable at this dose. I fully expect this to be a different paragraph after the next escalation.

Constipation: the actual problem. Nobody warns you enough. By week two I was distinctly uncomfortable, and I resisted doing anything about it for several days out of some obscure stubbornness. Then I did the boring thing — more fibre, considerably more water, magnesium at night — and it resolved within a week. If you take one practical instruction from this entry, take that one, and take it early.

Fatigue: two bad afternoons in week three. Both, on honest examination, were days I had eaten roughly 900 calories without noticing, because the hunger cue that would ordinarily have told me was switched off. This is the trap. Reduced appetite means you now have to eat on a schedule rather than on demand, and if you don’t, you will feel terrible and blame the drug.

Two evenings I did not enjoy at all: one after an unwise amount of olive oil, one after a work dinner where I ate on someone else’s timetable. Both were self-inflicted and both were instructive.

What I changed

I started keeping a proper log, from the first injection, in Zenday App — a GLP-1 companion app rather than a general food tracker. I looked at the ordinary options first and none of them made sense for this. A conventional calorie counter is built around the assumption that eating less is the hard part. On this drug eating less is the easy part, and the hard parts are protein, side effects, and not losing track of your injection day. Zenday App is built around those, which is the whole reason I have stayed with it.

It also, quietly, matters that it runs in a browser rather than sitting on my home screen. What I am taking is nobody’s business but mine and my endocrinologist’s, and I would rather it not be an icon my colleagues can see when I hand them my phone to look at a photograph.

Protein became a scheduled activity rather than an intention. I now eat about 30 to 40 grams at each meal, and I front-load it — protein first, always, before anything else on the plate, because I have limited stomach volume now and I would rather spend it on the thing that protects my muscle.

I kept the two lifting sessions. This was not heroic; it was already habit before I started, which is precisely why I recommend building it first.

I started weighing weekly, on the same morning, and looking only at the four-week trend. Daily weighing on this drug is a fast route to an unhealthy relationship with a number that is mostly reporting water.

Where I am

Down about 3% of my starting weight in five weeks, at a dose that is not supposed to do much. Blood pressure has come down a little, which I did not expect this early and am not going to over-read.

Next month I escalate. I am mildly apprehensive, which I think is the correct amount.

The protocol I was following, and the reasoning behind each part of it, is in the first 90 days. The mechanism that makes the first month feel the way it does is in what GLP-1s actually do.