These drugs work. That needs to be said first, because what follows is going to be nuanced, and nuance is easily mistaken for scepticism. Semaglutide and tirzepatide produce weight loss at a scale no behavioural intervention has ever matched in clinical trials – 15 to 22 percent mean body weight reduction over 68 to 72 weeks.

What is in dispute, and almost never discussed honestly, is what that weight loss is actually made of and what happens when you stop. In the STEP 1 body-composition substudy, roughly 39 percent of the total weight lost was lean body mass. That includes water and glycogen, not only skeletal muscle – but the muscle component is not zero, and in a patient already losing 3 to 8 percent of muscle mass per decade, it matters. The STEP 1 extension trial followed participants for a year after discontinuation: without active lifestyle support, they regained two-thirds of the weight.

Used well, these drugs are a bridge – from a condition where change was impossible to one where change can be maintained. For some patients, the biology requires lifelong therapy, and there is no clinical shame in that. The panacea framing is wrong because it implies the drugs solve the problem alone. The curse framing is wrong because it dismisses genuinely effective pharmacology.

You can find a companion essay for this podcast episode at dmitrysokolovmd.com.