semaglutide

 

Last August at my physical, the doctor offered weekly semaglutide injections. I passed, although I am heavier than standard. At my age with good numbers otherwise I tend to think the extra pounds have a small benefit and no need to use a relatively new drug. I read more and more about additional benefits and how it is changing lives, although I don't need that psychologically. Comment?

I think your decision last August was quite defensible—and I wouldn't look at the newer enthusiasm and conclude that you obviously made the wrong call.

What has changed is that semaglutide has turned out to be rather more than a weight-loss drug. The big SELECT trial found a roughly 20% reduction in major cardiovascular events in people with overweight/obesity and established cardiovascular disease, even without diabetes. Subsequent work has strengthened the case for cardiovascular and kidney benefits, and some of those benefits appear not to be simply a consequence of losing pounds.

But there's an important wrinkle in your situation. At 83, the question isn't simply "Would fewer pounds be healthier?" It's what are those pounds doing for you, and what would you lose along with them? Older people have less physiological reserve, and semaglutide-associated weight loss includes some lean mass. There is still uncertainty about how important that muscle loss is clinically, but it is a genuine concern in older adults.

And I rather like your instinct about the extra weight. If you're carrying some excess fat but you're otherwise metabolically doing well, a modest amount of reserve isn't necessarily your enemy at 83. The usual "get your BMI down to X" thinking is considerably less compelling in an older person than it is in a 35-year-old. The thing I'd care much more about is strength, mobility, balance, nutrition, cardiovascular health and whether the weight is causing an actual problem.

There's another point in your favor: you have already demonstrated that you can lose a lot of weight. Going from around 130 kg to the mid-90s is not a trivial change. If you're now stable and your doctor is satisfied with the rest of your numbers, I wouldn't see an obvious reason to chase another 10 or 15 kilograms merely because a calculator says you are overweight.

The newer evidence does make me somewhat more interested in semaglutide for someone in your position than I would have been a couple of years ago. But I'd distinguish two propositions:

"Semaglutide is an extraordinarily useful drug."
Yes.

"Therefore an 83-year-old who is somewhat overweight but otherwise doing well should take it."
No—that doesn't follow.

In fact, I think the psychological benefit you mention is almost beside the point. If you don't suffer from being overweight psychologically, you're not trying to fit into clothes, and you're not struggling to control eating, then one of the principal benefits for which people accept the drug's inconveniences simply isn't relevant to you.

There is also the practical question of how much benefit you could reasonably expect. The strongest cardiovascular evidence was in people with established cardiovascular disease. If your cardiovascular status is good, extrapolating that 20% reduction directly to you would be inappropriate. That's one place where the spectacular headlines about GLP-1 drugs can get ahead of the actual evidence.

So my present view would be: I wouldn't rush to start it. I would, however, regard your doctor's offer as considerably more interesting today than it seemed last August. If your doctor brought it up again, I'd ask a different question now—not "How much weight would I lose?" but "What specific health outcome are you expecting this to improve in me?"

If the answer is essentially "your BMI," I'd remain pretty relaxed about your decision.

If the answer is "given your particular cardiovascular/renal/metabolic risk profile, I think it will materially reduce your risk of X," that's a much more interesting conversation.

And your instinct that a little extra weight may be useful at your age isn't some eccentric old-man theory. The modern geriatric discussion increasingly emphasizes avoiding sarcopenia and frailty, not simply maximizing weight loss. That's precisely why clinicians are now cautioning that older patients taking these drugs need adequate nutrition and attention to muscle and function.

So I'd say: you probably passed on it for the right reasons, and the accumulating evidence doesn't make that decision foolish. It merely makes semaglutide worth reconsidering if there is a specific medical target beyond "you're overweight."

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