Phase 3: Making Your Shift
What is the issue?
We all need to consider that AI could replace us at our jobs one day.
But even before AI changed our world, anyone working in weight loss heard that the novel medications (like semaglutide or tirzepatide) would eliminate obesity in a few short years and so maybe they wouldn’t need obesity doctors like me.
For the first time in medical history, we have highly effective medications that reduce between 10% and 20% of body weight through appetite reduction and improved satiety signalling.
Predictably, the prevalence of obesity and overweight has only grown as these medications have become more available. These medications address one part of the equation: appetite. They do not improve metabolism. They do not independently or durably alter perspective.
Weight loss medications support your ability to regulate hunger and wanting, and to respond more effectively to their fluctuations during challenging times. These medications are not a replacement for your captaincy or the fundamental work of The Shift. Instead, they are a potential tailwind that can make the journey of managing your appetite and metabolism more navigable.
Many wonder if using medication is a sign of "failing" at lifestyle changes, or if it's taking an "easy way out." My profession has weaponized bias and stigma against people in larger bodies, making it harder for patients to get where they want to go. When people regain weight, which is the most common outcome of any diet, we make it very hard for them to come back to us because they think they've failed.
Medications for obesity are not about a lack of willpower. They are about addressing complex biology. My unit of interest is the appetite, and the appetite is a function of so many important body systems. Think of these medications as tools that can help recalibrate your ship's internal compass when powerful biological currents are pulling it off course. The goal is to make your own efforts more effective, not to replace them.
What do you think?
Before we dive into the science and specifics, I want you to pause and really think about this.
What are your current thoughts or beliefs about using medication for weight management?
Have you heard them described as a "crutch" or an "easy fix"? Perhaps a “silver bullet”?
What questions or concerns do you have about their safety, effectiveness, or long-term use?
Here's what I want you to consider: if you have high blood pressure, you take medication for it. If you have diabetes, you manage it medically. If you have depression, you might need medication to help your brain chemistry function better. Your appetite is regulated by the same brain structures that control all of these other functions. There's no moral difference.
Take a moment to jot down these reflections in your Captain's Log. Acknowledging your initial perspective is key to approaching this information with an open and informed mind. And if you're feeling resistance to the idea of medication, that's completely normal. Most of my patients feel that way initially.
What else would be good to know?
Here's what I see in my practice: People start a GLP-1 medication and suddenly they're like, "Wait, normal people don't think about food every 20 minutes?" The medication doesn't change who you are. It reveals what your appetite might feel like without all the biological headwinds working against you.
Pharmacological treatments are an effective and evidence-based approach to treating and preventing obesity. They are intended to make implementing your chosen tactics easier and to lower the effort required to execute your overall health strategy. Crucially, they can also make it easier to hear and strengthen your Inner Coach over the noise of headwinds.
Obesity medications aren't just for weight reduction. Their real value often lies in the improvement of overall health parameters. I've seen people's blood pressure go down, their cholesterol improve, their blood sugar normalize, even without dramatic weight loss. While your current weight or BMI is one factor, the decision to use medication is also heavily influenced by the presence, or significant risk, of complications from excess or dysfunctional fat.
The number of times people tell me, "I started Ozempic and all of a sudden I wanted a salad and I've never craved a salad in my life," is remarkable. It's because there's an anti-inflammatory influence to these medications that we haven't fully captured yet. You're healthier in ways that go beyond the number on the scale.
But here's what the guidelines won't tell you: not everyone responds to these medications. I see patients on semaglutide who don't lose any weight all the time. This isn't failure. Sometimes it's because we haven't found the right medication or the right dose yet. Sometimes it's because there are other headwinds that need to be addressed first.
How Medications Work as Tailwinds:
Weight loss medications don't magically "burn fat." Instead, they work on different aspects of your body's complex appetite and metabolic regulation systems.
Appetite Regulation: Some medications, like GLP-1 receptor agonists (e.g., liraglutide, semaglutide) and naltrexone/bupropion, act on brain centers that control hunger and wanting. They can make you more sensitive to appetite signals, make it easier to honour both hunger and wanting, and make it easier to step out of the eating experience. They help you feel satisfied with appropriate amounts of food and reduce the mental preoccupation with eating. When you can reduce that noise, suddenly your Inner Coach's voice becomes clearer. You can make Above Water eating choices because you're not constantly fighting overwhelming hunger or cravings. It's like turning down the volume on a radio that's been blasting static so you can finally hear the music.
Metabolic Signalling & Insulin Sensitization: GLP-1 receptor agonists also have beneficial effects on how your body handles glucose and insulin. They can improve insulin sensitivity, which is like making your engine run more efficiently on the fuel it receives. For some individuals, a medication like metformin might be used alongside these agents to further enhance insulin sensitization, acting as a "GLP-1 sparing" medication, helping you get "better juice from the squeeze" of the primary appetite medication.
Energy Absorption: One medication, orlistat, works by reducing the absorption of dietary fat in your intestines. This is like having a system that prevents some of the cargo (calories) from being fully loaded onto the vessel.
Key Considerations: The Shift Perspective
Here's where my approach differs significantly from standard medical care. Standard medication guides often talk about reaching a "maximum tolerated dose." That's not how I think about it. We focus on achieving your "target experience" with your appetite. This means finding a dose where you feel a noticeable, positive shift: less overwhelming hunger, reduced cravings, an increased ability to make Above Water eating choices, and a general sense of being more comfortable before, during and after eating.
This "target experience" tells us you're at the right dose for you, right now. It might not be the highest dose, and it may change over time. I've had patients feel dramatic improvement on doses that other doctors might consider "too low." What matters is what works for your appetite, not what the textbook says.
If you've been on a medication and feel it's "stopped working," it's rarely true tolerance like you see with opioids. More often, it's your body and mind adapting to the medication's effect at your current, often lower, weight. Your appetite iceberg is finding this new weight uncomfortable and fighting back. The conversation then isn't just about increasing the dose, but exploring how to make your body more comfortable in this new place.
Sometimes, especially with GLP-1 medications in people with significant insulin resistance, initial low doses might cause feelings of shakiness or intense hunger that feel like low blood sugar. Paradoxically, this can be a sign of the insulin resistance itself. In carefully selected cases, under expert guidance, a cautious increase in the GLP-1 dose might actually resolve these symptoms by improving overall insulin sensitivity. This requires careful medical supervision and someone who understands appetite physiology.
Let me be crystal clear about something else: obesity is a chronic condition, much like high blood pressure or type 2 diabetes. Therefore, medications used to treat it are often intended for long-term use to maintain their benefits. Weight regain is common when these medications are stopped, as the underlying biological pressures often reassert themselves. Your appetite remembers your highest weight, and it doesn't like being at a lower weight because it's worried that means you're sick.
This isn't failure. This is how chronic conditions work. The goal is often to find the lowest effective dose that helps you sustain your "target appetite experience" and health improvements for a nice long time.
Eligibility for Medication – Beyond Just BMI:
The decision to start pharmacotherapy considers several factors, moving beyond a simple BMI cutoff. We look at whether excess body fat is already causing measurable harm or dysfunction. If you have type 2 diabetes, prediabetes, insulin resistance, sleep apnea, fatty liver disease, or significant joint pain limiting mobility, then you have what we call clinical obesity. In these cases, medication is a strong consideration to treat the obesity and improve or resolve these complications.
If you have excess body fat but no current active illness caused by it, this is preclinical obesity. Medication might be considered if your risk of progressing to clinical obesity is very high or if temporary weight reduction is needed for another critical health intervention.
We also use ethnicity-adjusted BMI guidelines because standard BMI thresholds don't apply equally to all populations. For many ethnic groups, metabolic complications can occur at lower BMIs. Waist circumference and waist-to-height ratio help us assess central adiposity, which is a key indicator of metabolic risk.
Approved Medications in Canada:
(A brief overview here, the Visual Infographic activity will provide more detail)
GLP-1 Receptor Agonists:
Liraglutide 0.6 - 3.0 mg (Saxenda®): Daily injection. Generic options anticipated late 2025 in Canada.
Semaglutide 0.25 - 2.4 mg (Wegovy®): Weekly injection. Notably, semaglutidealso reduces the risk of major adverse cardiovascular events (like heart attack or stroke) in people with pre-existing cardiovascular disease and overweight/obesity, even if they don't have diabetes. This highlights these medications are about far more than just weight.
Oral Combination:
Naltrexone/Bupropion (Contrave®): Targets appetite and reward pathways.
Fat Absorption Inhibitor:
Orlistat (Xenical®): Blocks about 30% of dietary fat absorption
Important Off-Label & Emerging Options your doctor might discuss:
Tirzepatide (Mounjaro®/Zepbound®): A highly effective weekly injectable dual GIP/GLP-1 agonist. (Approved for diabetesas Mounjaro and for weight loss asZepbound in Canada).
Other forms of Semaglutide (Ozempic® - injectable, Rybelsus® - oral): These are approved for type 2 diabetes but are sometimes used off-label for weight management due to the same active ingredient as Wegovy®.
Metformin: Often used for insulin resistance and PCOS as an adjunct.
There are many other off-label medications for appetite and weight but they all should be used strategically to support the ones mentioned above based on your unique situation.
The choice of medication is highly individualized, considering your specific health profile, headwinds, preferences, side effect profiles, contraindications, potential interactions, and importantly, cost and insurance coverage. This last point is a real problem. These medications are expensive, and insurance often doesn't cover them, creating an ethical issue where effective treatments aren't accessible to everyone who needs them.
How do I apply this right now? How do I explore this more?
Understanding if medication is a suitable tailwind for your particular situation requires self-reflection and an informed discussion with your healthcare provider. But here's the thing: not all healthcare providers understand appetite physiology the way they should. You may need to advocate for yourself or find someone who specializes in this area.
Engage with these resources to become an informed Captain, able to discuss these options knowledgeably with your healthcare team.
You may stop reading the lesson and do these activities now or wait until the end of the lesson to do the activities in sequence.
Once you complete this lesson, the activities will appear on their own pages so you can find them and repeat them anytime.
If you have already completed the activity, click through by selecting ‘complete and continue’.
Activity 1:
Is Medication a Tailwind for Me? Should You Take Weight Loss Medication?
This quiz guides you through questions about your health, weight history, current challenges, and preferences. It's designed to help you clarify your own situation and prepare for a discussion with your Shift provider or personal doctor about whether pharmacotherapy aligns with your needs.
Activity 2:
What Are The Weight Loss Medication Options?
A comparative overview chart to help you and your doctor determine if medication is appropriate for you.
Activity 3: Resource Links
Navigating Support: Patient Programs for Weight Loss Medications in Canada
Accessing Patient Support Programs (PSPs) can be a valuable step in
managing your treatment with certain weight loss medications. These
programs are typically offered by the pharmaceutical manufacturers and
can sometimes help with the cost of medication (for eligible
patients), provide educational resources, offer nurse support or
injection training, and supply tools to help you on your journey.
Below are links and information for Canadian support programs related
to commonly discussed medications. Please note that program details,
eligibility criteria, and offerings can change, so it's always best to
visit the official program website or contact the manufacturer for the
most current information.
Wegovy® (semaglutide)
Novo Nordisk Canada Inc.
The Novo Nordisk Care® program supports Wegovy® patients. May include financial assistance information, injection training videos, educational articles, and reimbursement navigation.
Visit Novo Nordisk Care®Saxenda® (liraglutide)
Novo Nordisk Canada Inc.
SaxendaCare®, part of Novo Nordisk Care®, may offer co-pay assistance, nurse support, lifestyle management resources, and injection guides.
Visit Novo Nordisk Care® (Saxenda Info)Contrave® (naltrexone/bupropion)
Bausch Health, Canada.
The Experience Contrave® Program can provide reimbursement services, financial assistance information, adherence support, and educational resources.
Visit Contrave.ca Patient PortalSupport for Other Discussed Medications
The following medications might be discussed for weight management (potentially off-label in Canada). Their primary support programs are often geared towards their Health Canada-approved indications (e.g., type 2 diabetes) but may still offer valuable general medication support or resources.
Mounjaro® (tirzepatide)
Eli Lilly Canada Inc.
The mymounjaro™ Patient Support Program is for its approved diabetes indication. May offer savings cards (for eligible, commercially insured patients), injection support, and educational materials.
Visit Lilly Canada (Mounjaro Info)Ozempic® (semaglutide)
Novo Nordisk Canada Inc.
OzempicCare®, under Novo Nordisk Care®, supports patients with its diabetes indication. May offer reimbursement navigation, educational tools, and injection guides.
Visit Novo Nordisk Care® (Ozempic Info)Rybelsus® (semaglutide oral)
Novo Nordisk Canada Inc.
The Rybelsus® Reimbursement Navigation Program, part of Novo Nordisk Care®, helps with understanding coverage options for its diabetes indication and provides patient resources.
Visit Novo Nordisk Care® (Rybelsus Info)Important Disclaimer: The Shift Program provides this information for educational purposes only. We do not endorse any specific medication or Patient Support Program, nor are we directly affiliated with these pharmaceutical companies. The decision to use any medication should be made in consultation with your doctor. Eligibility for support programs and the specifics of their offerings are determined solely by the manufacturer and are subject to change. Always verify information directly with the program provider.
Pharmacotherapy Decision Tool
Patient and HCP considering obesity pharmacotherapy
Information given to patient regarding all available medications*
Advocate for access
Consider goals of therapy**, contraindications, and patient values and
preferences***
Start medication *
Assess efficacy after 3-6 months on therapeutic dose
Treatment goals not met
Treatment goals met
Add or substitute another medication
Continue medication
Reassess goals of therapy** and patient values and preferences***
periodically
Details
Click on any box in the flowchart to see more details here.
Footnotes:
* Medications approved in Canada as of June 2022: Liraglutide 3 mg daily, Naltrexone/Bupropion 16/180 mg bid, Orlistat 120 mg tid, Semaglutide 2.4 mg weekly.
** Goals of therapy: Treatment of comorbidities, percentage and durability of weight loss.
*** Patient values and preferences: Including cost, frequency, route of administration and tolerability.
How do I bring it all together?
Medications, when appropriate, are a powerful tailwind. They are not a failure of other efforts but a recognition of the profound biological nature of obesity.
Using medication doesn't mean you're weak or that you haven't tried hard enough. It means you're being smart about working with your biology instead of against it.
The Shift approach is to integrate medications wisely to support Above Water eating by reducing the appetite chaos, creating more space for your conscious, Coach-led food choices. When your biology feels less overwhelming, your Coach's voice can become clearer and more influential.
These medications can directly counteract biological headwinds like insulin resistance or strong genetic predispositions to higher appetite. They're a tactic to help you achieve your broader health and 10/10 life objectives, not an end in themselves.
But let's also be honest about what they can't do. They can't solve all the headwinds in your life. They can't fix your sleep, your stress, your relationship with food, or your Inner Critic. They work best when integrated with all the other tools you've been building in The Shift.
How will I know if this is making a difference? How do I start noticing the changes?
If medication becomes part of your plan, look for these signs of a helpful tailwind. The most important thing is a shift in your "appetite experience." You might notice reduced baseline hunger, feeling satisfied with smaller portions, diminished cravings or less "food noise," and a greater sense of ease around food decisions.
Many people describe it as suddenly realizing they can leave food on their plate without thinking about it, or that they're not planning their next meal while eating their current one. The constant mental chatter about food starts to quiet down.
You may see clinically meaningful weight loss, typically defined as 5% or more of initial body weight after three to six months on an effective dose, though this varies significantly between people. You might also see improved health markers like blood pressure, blood sugar, or cholesterol levels, and symptoms of conditions like sleep apnea or joint pain might improve.
Enhanced quality of life is huge. Increased energy, better mood, improved physical function, or simply feeling more comfortable and capable in your vessel are all meaningful changes.
Track these changes in your Ship's Manifest and Captain's Log. Regular check-ins with your doctor are crucial to monitor effectiveness, manage any side effects, and ensure the medication remains the right fit for you. Remember, this is often a long-term partnership, not a quick fix.
What is next?
You now have a more nuanced understanding of how weight loss medications can serve as a strategic tailwind. Our next lesson moves from medical interventions to a universally beneficial tailwind available to every Captain: Movement.
We'll explore how purposeful movement isn't just about exertion, but about powerfully propelling your vessel and enhancing your overall capacity to navigate.