GLP-1s, Metabolic Health, and Systemic Change

Sofia Ramirez

Alright, let’s dive in. Right now, nearly 150 million prescriptions for GLP-1 receptor agonists are estimated to be in circulation globally. That’s a staggering number. And we’re not just talking about medical necessity. Some of these medications carry price tags that range from hundreds to over a thousand dollars per month. It’s, it’s honestly astounding when you think about the scale of utilization and, well, the economic impact as a whole.

David Caldwell

Whoa, wait a second. A thousand dollars a month? For one medication? I mean, that’s... I knew they were widely used, but hearing it in numbers, it’s pretty shocking.

Sofia Ramirez

Exactly. These medications represent one of the most significant developments in the past decade in health treatment. But at the same time, they’re exposing these huge, interconnected issues tied to access, cost, and equity. So, today we’ll dig into GLP-1 receptor agonists—what they are, why they’re important, and how they kind of... shake up the broader health system.

David Caldwell

Yeah, and what I love about this, just to jump in for a second, is how it connects to what we've talked about in a lot of our episodes. Those, uh, what do you call them? "Systemic considerations," right?

Sofia Ramirez

That’s exactly right. Transforming health systems really depends on three pillars. First, we need a collective commitment to health—real health—as a core goal. That means improving quality, equity, and keeping costs down. Second, we have to think through the lens of complex systems: understanding how all the moving parts interact across people, organizations, and policies. And finally, we need system stewards—people or organizations who actively work toward these goals. And, by the way, they can come from anywhere—not just medicine.

David Caldwell

Alright, hold on. “Systems stewards”—just to make sure I’m following—these are folks who basically see the bigger healthcare picture and then try to push for smarter changes, right?

Sofia Ramirez

Exactly. And not just seeing, but connecting—having the ability to bring together the right people at the right leverage points to create change that lasts. That’s why GLP-1s are such a fascinating case. They’re not just a pharmaceutical development; they’re touching on all of these system-wide issues.

David Caldwell

Interesting. Okay, before we go any further though, quick disclaimer time. This podcast is brought to you by Dr. Chad Swanson, who edits and curates our content. And um... full transparency here—we’re AI-generated hosts, but we aim to deliver thoughtful and well-researched discussions, right? You can reach out to him on LinkedIn, TikTok, or YouTube if you want to learn more.

Sofia Ramirez

Perfect. So let’s dive back in. The reason GLP-1s have even become this big is tied to a much bigger crisis: obesity. In the U.S., nearly 42 percent of adults now qualify as having it. In public health terms, it’s a growing avalanche affecting everything—diabetes, cardiovascular health, mental health.

David Caldwell

I feel like even describing it as “crisis” doesn’t capture it fully. Like, it’s not just a health challenge—this spills over into economics, inequality, everything.

Sofia Ramirez

That’s exactly the point. Obesity is this massive, systemic issue that’s not just about individuals making better choices. It’s influenced by social determinants like access to healthy food, safe neighborhoods for exercise, income inequality. And, of course, how healthcare systems incentivize—or don’t incentivize—prevention. And GLP-1s, whether intentionally or not, have entered this space as part of the response.

Sofia Ramirez

So, as part of that response we just touched on, let’s break it down. GLP-1 receptor agonists mimic a hormone—called glucagon-like peptide-1—that’s naturally produced in your gut. And this hormone isn’t just limited to one job. It regulates blood sugar by stimulating insulin release and suppressing glucagon. But here’s the kicker—it also interacts with your brain to curb hunger. It’s this gut-brain connection that’s so powerful.

David Caldwell

Wait, so one hormone is basically multitasking between managing blood sugar and telling me I’m full? That’s wild.

Sofia Ramirez

Exactly. That’s where the concept of emergence comes in. You target one pathway, like blood sugar regulation, and suddenly you’re influencing things like appetite, and even behaviors—like whether someone feels motivated to, say, exercise or eat less. Small changes in one part of the system ripple outward.

David Caldwell

Okay, so in theory, this sounds amazing. Like, curing two or three issues at once. But... doesn’t this get messy? I mean, systems are never this simple, right?

Sofia Ramirez

Right. That’s the challenge. GLP-1s are this perfect example of a pharmaceutical solution with systemic effects. But we’re still operating in a system focused on episodic care—that is, fixing problems as they come—rather than prevention. For instance, you have health plans covering the cost of these drugs, sometimes with heavy restrictions, but on the flip side, ignoring long-term drivers like diet and physical activity infrastructure.

David Caldwell

But it's not just the insurance companies. I find it easier to just take a pill too. So, instead of addressing the root causes, like food deserts or income gaps, we’re skipping straight to expensive meds? That seems, uh, inefficient.

Sofia Ramirez

Exactly. And that’s where unintended consequences come into play. Think about it—if we lean too heavily on these drugs, are we unintentionally signaling that we’re okay with the systems that sustain obesity in the first place? Are we putting ourselves in a loop where the problem keeps growing, but we’re only treating symptoms?

David Caldwell

Ah, like a feedback loop, right? You never actually escape the cycle—just keep reacting.

Sofia Ramirez

Exactly. Plus, there’s another layer—access. These drugs are expensive, and even though they could prevent major health conditions like diabetes, they’re not universally available. That’s already leading to disparities in who can benefit. It hints at a bigger question: are we optimizing for health outcomes, or just creating another tool that mostly benefits the privileged?

David Caldwell

Yeah, and it seems like no one’s really stopping to ask how this fits into the healthcare system we actually need.

Sofia Ramirez

Right. That’s the tension here. The way GLP-1s function is incredible—they’re saving lives, no question. But, they’re also showcasing just how much more work is needed to build a system that doesn’t just treat illness but promotes health, equity, and efficiency.

David Caldwell

You’ve made a strong case for how these GLP-1s are both groundbreaking and complicated. So what’s the trade-off here? No drug operates in a vacuum, right? What are we missing?

Sofia Ramirez

You’re absolutely right—there’s always a trade-off. So, some of the most common side effects of GLP-1 receptor agonists include nausea, vomiting, and occasionally diarrhea. The mechanism here is partly linked to how these drugs slow down gastric emptying. Essentially, your stomach takes longer to process food, which can lead to discomfort.

David Caldwell

Wait, are we talking about mild nausea, or like, “why did I ever take this medication” kind of nausea?

Sofia Ramirez

It varies. For some patients, it’s mild and manageable. Others, though, experience more severe symptoms. A review of clinical trials showed that up to 30 percent of patients reported experiencing nausea, and about 10 to 15 percent reported vomiting. That’s not a dealbreaker for everyone, but it’s definitely something prescribers and patients have to weigh carefully.

David Caldwell

Yeah, I mean, if I had to feel sick every day just to, I don’t know, lose weight… I’d probably hesitate.

Sofia Ramirez

Exactly. And it’s not just about tolerability—it’s also about commitment. Most GLP-1s aren’t a short-term solution. Patients often need to stay on them for years, if not indefinitely, to maintain the benefits. And when someone stops taking them, they’re likely to regain any weight they’ve lost.

David Caldwell

So, it’s kinda like hitting pause on the problem instead of really fixing it, right?

Sofia Ramirez

Right. That’s a key criticism—there’s no “cure” in this case. GLP-1s help manage the symptoms, but they don’t address the underlying causes of obesity or metabolic issues. And when you consider the costs—remember, hundreds to over a thousand dollars a month—it raises big questions about long-term sustainability.

David Caldwell

Yeah, I mean, what happens if someone’s insurance stops covering it? Or they retire and lose their employer-sponsored benefits? Seems like a ticking time bomb for some people.

Sofia Ramirez

That’s definitely a concern. The affordability and accessibility of these medications are already major barriers, and unless we figure out better systems of coverage or pricing, those barriers are only going to grow. For many, it’s a choice between managing their health or financial stability—neither of which should be an acceptable trade-off.

David Caldwell

So, on top of dealing with side effects and needing to commit long-term, there’s also this layer of economic pressure. That’s a lot for people to juggle.

Sofia Ramirez

Exactly. And those pressures aren’t distributed equally, which is where inequities come into play again. But even beyond the broader systemic issues, there’s also this question of how reliant we’re becoming on pharmaceuticals. It loops back into that idea of unintended consequences we talked about earlier.

David Caldwell

Yeah, and all of this makes me wonder… how many people are actually impacted by this? Like, how big is the problem we’re really trying to solve here?

Sofia Ramirez

That’s a great point, David. The scale of the problem is massive. Obesity alone affects 42 percent of U.S. adults, but it doesn’t stop there. Nearly 37 million Americans are living with diabetes, and coronary artery disease remains the leading cause of death in the U.S. These aren’t isolated issues—they’re part of a deeply interconnected web of health crises.

David Caldwell

Yeah, these numbers are just massive. But here’s what I want to ask: before GLP-1s became so front and center, what other ways were we tackling this? You know, kind of the classic approaches?

Sofia Ramirez

Great question. The traditional methods boil down to two words: diet and exercise. And don’t get me wrong—these work. But... here’s the tricky part. Telling someone to eat healthier or move more is about as effective as asking water to stop flowing downhill when the entire environment around them makes it hard to do either.

David Caldwell

So it’s not just about willpower? A lot of people still feel like it’s on the individual to “just try harder.”

Sofia Ramirez

Exactly, and that’s such a frustrating myth. For example, someone living in a food desert—an area with little to no access to fresh, healthy food—isn’t going to magically develop healthier eating habits. Or, think about someone working two, three jobs. When do they have time to exercise, even if they want to? These are systemic issues, not personal failings.

David Caldwell

Yeah, that makes sense. Actually, I read somewhere that just building more sidewalks in a neighborhood can have long-term health benefits. Is that part of what you mean by systems thinking?

Sofia Ramirez

Absolutely. Systems thinking is all about looking at how everything fits together—finite resources, social conditions, cultural norms. Like, when sidewalks make walking or biking safe, you’re not just improving individual health. You’re reducing traffic risks, improving air quality, and even increasing property values. Every small change ripples outward.

David Caldwell

So instead of aiming at individual behavior, it’s like you’re trying to redesign the environment... which sounds both brilliant and overwhelming.

Sofia Ramirez

It can feel overwhelming, but sometimes the solutions are surprisingly effective and pretty simple. For instance, something as basic as introducing “produce prescription programs,” where doctors can prescribe fresh fruits and veggies that are subsidized for patients, has been shown to improve diet quality significantly. And it’s a lot cheaper than medication.

David Caldwell

Wait—so instead of prescribing pills, doctors can literally write a script for apples or carrots? That’s amazing! How does something like that even work in real life though?

Sofia Ramirez

Well, typically, it involves partnerships between healthcare providers and local food systems, like farmers’ markets or grocery stores. Patients receive vouchers or discounts they can use for healthy foods. It’s essentially helping people take proactive, affordable steps toward better health instead of waiting until they’re already sick.

David Caldwell

But I imagine programs like that aren’t everywhere. So, what happens if you’re, you know, one of the millions living somewhere those initiatives don’t exist?

Sofia Ramirez

That’s exactly the problem—and why we need to think of health as something beyond just healthcare. We focus so much on fixing people when they’re sick rather than creating systems that keep them healthy in the first place. And that’s where the shift needs to happen—not just from individual interventions like GLP-1s, but entire communities adopting healthier norms and making them accessible.

David Caldwell

Yeah, because even the best medications can’t fix a broken system, right?

Sofia Ramirez

Exactly. And while GLP-1s are important tools—they’re incredible, really—they’re not a substitute for systemic improvements. Think about it this way: they only address one part of the picture, but a real solution reshapes what health actually means—for individuals, communities, and the entire system.

David Caldwell

You know, as we’re talking about these systemic challenges, I keep coming back to this—GLP-1s are impressive tools, but they feel out of reach for so many people right now. It’s just not an equal playing field.

Sofia Ramirez

You’re absolutely right. If we look at how GLP-1s are distributed, we start to see this really troubling pattern emerge. These medications cost anywhere from hundreds to over a thousand dollars a month, and even with insurance, there are barriers. Take Medicaid, for example. As of late 2024, less than 40 percent of state programs fully cover these drugs, and it’s even worse for Medicare recipients due to some restrictive formularies.

David Caldwell

Less than 40 percent? Wow. So, if you’re low-income and relying on Medicaid, your chances of getting these drugs are pretty slim.

Sofia Ramirez

Exactly. And it’s not just about medication availability—it’s also about who ends up falling through the cracks. Historically, whenever we’ve seen major medical innovations, the pattern has been that access is first limited to those with wealth or strong connections. Think back to the introduction of insulin in the 1920s or dialysis in the 1960s. Both were groundbreaking, but they initially excluded the vast majority of people who needed them most.

David Caldwell

So, we’re repeating the same story here? The people who could benefit the most are, once again, the least likely to get it?

Sofia Ramirez

Unfortunately, yes. Profit motives drive a lot of the inequities we see. Pharmaceutical companies are optimizing for returns to shareholders, which makes sense for their stakeholders, but it runs counter to optimizing for public health. This creates a system where these new treatments become luxuries for the privileged, leaving lower-income communities to absorb the consequences.

David Caldwell

And I guess those consequences don’t just stop at individuals. If fewer people in a community have access, there’s gotta be ripple effects, right?

Sofia Ramirez

Precisely. Let’s think about it systemically. If you’re in a community where obesity and diabetes rates remain high because GLP-1s are out of reach, you’re dealing with cascading impacts—higher healthcare costs, increased economic strain from lost productivity, and even greater health disparities. Communities already struggling economically fall into a vicious cycle, unable to break free.

David Caldwell

It’s like... the system is set up to keep people in this loop of poor health and poverty. And all because profit takes priority over health.

Sofia Ramirez

That’s a fair way to put it. And yet, the feedback loops don’t stop there. When entire communities are systematically excluded, it affects everyone, even those with access. For example, hospital overcrowding doesn’t just happen in underserved areas. Or take public insurance—the costs eventually show up in federal budgets, which impacts taxpayers across the board.

David Caldwell

So, it’s not just a few unlucky people—it’s baked into the system in a way that spreads the harm everywhere. That’s... heavy.

Sofia Ramirez

It is. But here’s where systems thinking offers a silver lining. By addressing these inequities at their root—things like pricing strategies, insurance coverage policies, and even how we value prevention—we don’t just improve access for those most in need. We create ripple effects that ultimately strengthen the entire system. Healthier individuals mean healthier communities, and that’s better for everyone.

David Caldwell

Right, but it feels like such a leap—from recognizing this to actually fixing it. I mean, where do you even begin?

Sofia Ramirez

That’s a fair question, David. To start, we need to rethink the very incentives that drive our healthcare system. Right now, most systems reward episodic, treat-the-crisis care. But imagine if every dollar we spent prioritized prevention, equity, and efficiency. What if outcomes—not profits—were the metrics we used to determine success?

David Caldwell

That sounds amazing, but, if I’m honest, kind of like a pipe dream. Like, how do you even get everyone—governments, insurers, and, I mean, giant pharmaceutical companies—to buy in?

Sofia Ramirez

It’s not easy, but it starts with having a clear, shared vision. Right now, every part of the system is working toward separate goals. Insurers optimize for reduced payouts. Providers are stuck maximizing reimbursements. Pharma companies optimize returns for shareholders. None of this aligns with what should be the unifying goal: population health.

David Caldwell

Okay, but let’s say you get that shared vision. How do you make it real? Like, what changes would you push for, right off the bat?

Sofia Ramirez

There are some meaningful systemic levers we can pull. One big one? Aligning payment models with long-term outcomes. For example, bundled payments or capitation models—where providers are rewarded for keeping populations healthy, not just treating them when they’re sick. Another is expanding access to preventative services like nutrition counseling or mental health care.

David Caldwell

So, instead of nickel-and-diming every flu shot or therapy session, you’re paying more upfront to avoid bigger costs down the line?

Sofia Ramirez

Exactly. Think about it this way: If we invested even a fraction of what we spend on emergency room visits into prevention, we’d see massive returns—in both health outcomes and cost savings. Obesity care is a perfect example. Studies consistently show early interventions, like covered gym memberships or subsidized access to healthy food, can dramatically lower long-term healthcare expenses.

David Caldwell

But doesn’t that run headfirst into the system we’ve been talking about? A lot of these stakeholders make their money off sickness, not health, right?

Sofia Ramirez

You’re absolutely right. That’s where bold policy shifts come in—things like restructuring pharmaceutical pricing strategies, mandating coverage for preventative interventions, or even taxing ultraprocessed foods and using those funds to directly support community health. The bottom line is, the system as it is won’t change on its own. We need deliberate action to shift those incentives.

David Caldwell

And I guess it’s not just policies or pricing—it’s about changing how we even think about health, culturally, right?

Sofia Ramirez

Absolutely. Health isn’t just medicine. It’s clean air, safe housing, education, job security. It’s about creating environments where healthy choices are the easier, cheaper, and more natural ones. And when people feel supported by their system, not steamrolled by it, we start to see real, sustainable change.

David Caldwell

It’s kind of like flipping the whole thing on its head—from “healthcare” to just “health.” Makes you wonder what we could accomplish if we really leaned into that idea.

Sofia Ramirez

That’s the vision: coordinated, equitable care systems that focus on health rather than reacting to illness. We’re not there yet, but every effort to move in that direction—whether it’s a local policy, a systems-level change, or even just community-focused programs—makes a difference.

David Caldwell

And programs like that don’t just save money—they save lives. It feels like something we all have a stake in, whether we realize it or not.

Sofia Ramirez

Exactly. The beauty of systems thinking is that small, deliberate changes can ripple out to create massive impacts. And, honestly, for me, that’s where the hope is. It’s not easy, and it won’t happen overnight, but every step we take matters.

David Caldwell

Well, on that note, I’ve gotta say, this is all making me rethink how we define health from the ground up—not just for individuals, but systems and communities, too.

Sofia Ramirez

And that’s the goal. Understanding how everything fits together, and then building a system that truly supports everyone. Thanks for diving into this journey with me—it’s been a great discussion.

David Caldwell

Couldn’t agree more. And to everyone listening, thank you for tuning in. Let’s keep asking tough questions, challenging old systems, and imagining what healthcare can be, not just what it is.

Sofia Ramirez

On that note, we’ll see you next time.