Weight management sits inside this practice rather than beside it, for a reason that is easy to miss. Body weight is one of the strongest modifiable influences on almost everything else we treat: erectile function, testosterone, fertility, urinary symptoms, sleep apnea, incontinence, fibroid symptoms, PCOS, blood pressure, joint pain and the risk of the cancers we screen for. A urology practice that ignores weight is treating the downstream problems and leaving the upstream one alone.
What changed
For most of the history of obesity medicine, the available drugs produced a few percent of weight loss and the honest advice was that diet and exercise were the whole game. That is no longer true. The GLP-1 receptor agonists, and the dual GLP-1/GIP agonists that followed, produce weight loss of a magnitude that previously required surgery. They work by slowing gastric emptying and, more importantly, by acting on the appetite centres of the brain — which is why patients describe the effect not as willpower but as the constant background negotiation about food simply going quiet.
Their benefits extend past weight. Cardiovascular outcomes improved in people with established cardiovascular disease and obesity; kidney outcomes improved in people with type 2 diabetes and chronic kidney disease; sleep apnea severity improved. These are meaningful findings, and they are why we treat these drugs as cardiometabolic medicine rather than as cosmetic assistance.
What the marketing leaves out
Three things, and we would rather you heard them here.
The first is muscle. A substantial fraction of the weight lost on these drugs is lean mass, and lean mass is not a cosmetic concern — it is the tissue that determines metabolic rate, insulin sensitivity, bone loading and, further out, whether you can get out of a chair unaided at eighty. Losing thirty pounds of which a third is muscle is a worse outcome than losing twenty of which almost none is. This is why our programme measures body composition rather than weight alone, sets protein intake deliberately, and treats resistance training as part of the prescription rather than as advice. It is also why the longevity programme's interest in grip strength and lean mass is not a separate topic from weight loss.
The second is stopping. Appetite regulation returns when the drug is withdrawn, and in the trials most of the lost weight returned with it. That is not a failure of the patient or the drug; it is what treating a chronic condition with a drug that is then stopped looks like, and nobody is surprised when blood pressure rises after stopping an antihypertensive. It does mean the decision to start should be taken with a realistic view of duration, cost and what an exit plan looks like.
The third is side effects and supply. Nausea, vomiting, constipation and reflux are common and are usually manageable with slower titration. Gallbladder disease and pancreatitis are uncommon but real. There is a thyroid C-cell tumour signal from rodent studies that makes these drugs contraindicated in people with medullary thyroid carcinoma or MEN2. And compounded versions sold outside the ordinary supply chain have been a genuine safety problem: dosing errors from vial concentration confusion have caused hospitalisations. We offer GLP-1 treatment after an individualized assessment.
What a visit includes
History and medication review, blood pressure, waist measurement, body composition, and bloods — HbA1c or fasting glucose, lipids, liver and kidney function, thyroid, and testosterone in men where symptoms warrant it. Sleep apnea is screened for, because it is common at higher weights, it worsens metabolic health, and treating it changes how well everything else works.
Where weight and urology meet
Adipose tissue is hormonally active: it converts testosterone to estradiol, which is one reason obesity lowers testosterone and why weight loss raises it without any hormone being prescribed. We would rather achieve that first and see where the numbers land than start a man on testosterone whose low level is a consequence of his weight and whose fertility would then be suppressed unnecessarily.
Erectile function is vascular before it is anything else, and the same endothelial dysfunction that weight drives is the reason erectile dysfunction is an early warning of cardiovascular disease rather than a separate nuisance. Weight also worsens urinary incontinence in women, PCOS, fibroid symptoms and nocturia through sleep apnea. None of this is a lecture — it is the reason the programme sits where it does.
What we actually do
We start by establishing what kind of problem this is: a weight that has crept up on a stable pattern of eating, a weight driven by a medication, a weight driven by untreated sleep apnea or hypothyroidism, or a pattern of appetite that has never been quiet. The answers point in different directions, and for a meaningful number of patients the right first intervention is not a drug at all.
Where medication is appropriate, we consider GLP-1 or GLP-1/GIP treatment and titrate slowly, because the patients who fail on these drugs usually fail on side effects during escalation rather than on efficacy. Protein targets and resistance training are set at the start rather than added when the DEXA looks wrong. We recheck body composition rather than only weight, and we plan for what happens after target is reached, including whether a lower maintenance dose is enough.
The counselling that underlies all of this was written up at length by Dr. Shusterman in The Non-Seefood Diet, which patients in the programme are welcome to read.
Questions patients ask
Do I have to stay on the medication forever?
Possibly, and you should decide with that in mind. Appetite regulation returns when the drug stops and most people regain a large share of the weight. Some patients maintain on a reduced dose, and some maintain after a long period at target with established training and eating patterns. What we will not do is imply that a short course produces a permanent result.
Will I lose muscle?
Some, unavoidably — that happens with any substantial weight loss. How much is strongly influenced by protein intake and resistance training, which is why both are part of the prescription and why we measure body composition rather than weight alone. Losing weight while preserving lean mass is the actual goal.
Is compounded semaglutide a reasonable way to save money?
Our practice offers GLP-1 treatment. Your clinician will discuss the specific medication, whether it is FDA-approved, dosing, cost, and monitoring. Compounded drugs are not FDA-approved; they require particular care with product quality and dosing and should only be considered when an available approved drug cannot meet a patient’s medical needs.
Can these drugs help if my BMI is normal but I carry weight around the middle?
Central adiposity carries metabolic risk that BMI hides, and waist measurement and body composition capture it better. Whether medication is appropriate depends on the whole picture including glucose, lipids and blood pressure rather than on a single number, and for some patients the answer is training and diet rather than a prescription.
Does insurance cover it?
Coverage varies widely and is the most common obstacle patients hit. Many plans cover these medications for diabetes and are more restrictive for obesity alone; some require documented prior attempts. We check benefits before prescribing so you are not surprised at the pharmacy.
Sources
Make an appointment
Manhattan (212) 991-9991 · Forest Hills (718) 360-9550 · same-week visits and all insurance accepted, including Medicaid and Medicare.