Why I Started

I am going to write this whole section in the first person, and I have thought carefully about whether that is wise.

The argument against is obvious. I am a physician. My credibility rests on the distance between my judgement and my personal experience, and there is a real risk that publishing my own case turns a medical writer into a wellness influencer with a stethoscope. I have watched that transformation happen to people I respected. It rarely reverses.

The argument for won, and it is this. Over the last 2 years I have had some version of the same conversation several hundred times, and the part my patients most want and least receive is not the pharmacology. It is somebody being honest about what the year is actually like. What the first month feels like. What you tell your friends. What happens to your relationship with dinner. Whether the thing that felt like relief also felt, briefly, like grief.

I could not find that written by anybody with the training to also tell you what is happening physiologically underneath it. So I am going to try.

The 2 year gap

I started prescribing GLP-1 receptor agonists for weight management in earnest about 2 years before I took one. In that window I got quite good at the conversation. I could counsel on titration, I could pre-empt the constipation, I could write a letter of medical necessity that got approved more often than not.

And in that entire period, it did not seriously occur to me that the drug applied to me.

I want to be precise about why, because the reason is not flattering and it is extremely common.

My BMI sat in the low thirties. My blood pressure had crept from ideal to high normal to we should watch this. My fasting insulin was doing something I would have flagged instantly in a patient. I am 47, squarely in perimenopause, and I have written — with some authority — about exactly what happens to body composition in the years I was living through.

I knew all of it. I looked at all of it. And I thought: yes, but I’m the doctor.

The specific vanity of being the doctor

There is a particular delusion available to clinicians, which is that understanding a mechanism confers some immunity to it. That because I could draw the pathway on a napkin, I was somehow operating one level above the pathway.

It is nonsense, and it is nearly universal in medicine. Physicians are famously bad patients. We defer our own screening. We treat our symptoms as interesting rather than actionable. And when the condition in question carries stigma — and obesity carries an enormous amount of stigma, including inside medicine, including from doctors, in the documented way patients keep telling us about — the deferral gets a moral flavour.

Because here is the thing I have to admit if I am going to write this honestly. I did not think I needed the drug. I thought I needed to be better. Better organised, better rested, better at the 6 a.m. workout I kept scheduling and skipping. I had a decade of evidence that the better-version-of-me plan did not work, and I kept re-running it, because the alternative felt like conceding something.

I have never once let a patient reason that way in front of me. I would have gently taken it apart. I let myself do it for years.

What actually changed my mind

Not a number. A Tuesday.

I had a patient — mid-fifties, PCOS, twenty years of being told to try harder by people who should have known better — who had been on semaglutide for about 8 months. She was describing what it was like to not think about food constantly. She said the thing I have now heard hundreds of times, that the noise stopped, and then she said something I had not heard before.

She said: I didn’t know other people were living like this the whole time.

And I sat there and realised, with total clarity and considerable embarrassment, that I had been assuming my own experience of hunger was the baseline one. That the running negotiation in the back of my head, from about 3 p.m. onward, every day, for as long as I could remember, was simply what having a body was.

It might not be. That was a genuinely destabilising thought and it took me about 2 months to do anything with it.

What I did before starting

I am a great believer in doing the boring parts first, and I had already done some of them, which is why I want to say clearly: this is not a story about the drug replacing effort.

6 months before I started, I began lifting seriously. Twice a week, with a trainer for the first eight sessions because my form was terrible and my ego was worse. That is the single best decision in this entire chronicle and I made it before any prescription existed.

I also got baseline data, because I would demand it of a patient: comprehensive metabolic panel, lipids, HbA1c, fasting insulin, thyroid studies, and a DXA scan. The DXA I paid for myself and it was not cheap. I wanted a real body-composition baseline rather than a scale number, for reasons I have written about at length.

And I sorted out my own care. I am not prescribing for myself. I have a physician — an endocrinologist I have referred patients to for years, which was its own small humbling — and she is the one making these decisions. Self-prescribing in this class of drug is a bad idea for the same reasons it is a bad idea in every other class, plus the additional reason that nobody can see their own case clearly.

One editorial decision

I am not going to publish my weight.

Not the starting number, not the current number, not the target. I have thought about this a lot and I keep landing in the same place: a specific number invites a specific comparison, and the comparison is almost never useful and frequently corrosive. Somebody will read my starting weight and feel worse about theirs. Somebody will read my target and adopt it, and it will be wrong for them.

What I will publish is percentages, doses, labs, body composition, and how things actually feel. Those are the things that transfer.

Where this is going

I have a first prescription. I have not filled it yet. I am, I notice, slightly dreading the part where I tell people — which is interesting, given that I have spent 2 years telling patients they have nothing to be ashamed of.

Apparently I believed that sentence at about ninety percent.

The next entry will be from the other side of the first 4 weeks. I intend to write it while it is still uncomfortable, before the retrospective gloss sets in and I start describing it as easier than it was.

If you are at this point yourself, the two things I would read first are what GLP-1s actually do, because understanding the mechanism changed how I felt about taking it, and who should not take a GLP-1, because that conversation should happen before the prescription rather than after.