CrossFit’s philosophy of health is rooted in personal accountability and independence. You get out what you put in. Education is central to the CrossFit methodology, so as your fitness grows, so does your knowledge base. Our goal as coaches and owners is to guide those who have entrusted us with their health to become fit, informed, self-reliant humans. We strive to maintain fitness over time — otherwise known as health — through our culture of radical candor, accountability, and communal support.
This stands in stark contrast to our current mainstream medical model and its disproportionate reliance on pharmaceuticals. When profit is created through the management of disease, allocating time and resources toward addressing the root cause stands at odds with the business model. The economic engine of medicine requires our diseased dependency, and the longer the better. Pharmacologic interventions, especially for children, are recommended at unprecedented rates [1]. Between 2020 and 2023, the prescription rate of Glucagon-like Peptide -1 receptor agonists (GLP-1 RAs) to adolescents increased by over 594% [2]. Shareholders rejoice in the profit, but the trickle down is that our kids learn to outsource the answers to their problems instead of looking within themselves. They learn that solutions are found in pills or procedures, not through habit formation or choice, and that their current state is a forgone conclusion, there to be managed by outside forces, as opposed to changed from within.
This is not to demonize the use of medications when they are appropriate, for often they are. But our unilateral dependence on them as opposed to being part of a comprehensive treatment strategy addressing root causes is short-sighted and suboptimal. We must do a better job of educating and supporting healthy habit formation for lifestyle-driven diseases. This is not about blaming the victim; this is a wake-up call to my physician colleagues to do more than pay lip service to exercise and nutrition. This is a call to follow the guidelines as they are actually written.
This trend is not new. For decades, we have let the miracle of scientific development obfuscate our personal responsibility as a medical community. This dynamic is not the result of informed choice on the part of our patients, but rather the product of our medical education system and habits within our practices that create disproportionate dependence on pharmaceuticals as the lone solution, as opposed to an adjunctive therapy.
In particular, the widespread adoption of GLP-1 RAs as the much-celebrated solution to our obesity epidemic has highlighted our hypocritical approach to health creation as providers. If we practiced true shared decision making and informed consent, implementation and utilization of this class of medications would be much different. We would minimize side effects, improve treatment outcomes, and ultimately guide our patients toward a drug-free future, not a lifelong state of dependence.
While they may seem new, GLP-1 RAs have been FDA-approved for over 20 years. Initially developed to treat diabetes, the impacts on central satiety, combined with delayed gastric emptying, proved to be the most powerful pharmaceutical weight-loss intervention we have seen to date. The potential positive impacts in helping to slow cognitive decline, cardiovascular disease, and autoimmune dysfunction are intriguing and continue to be explored [3-5]. GLP-1 RAs also appear to modulate reward pathways in the brain, which is why some individuals have found they are able to drink less alcohol or even give up smoking [6]. But with any medication, there are always potential risks and unintended consequences. Often, these may not be realized for years or even decades.
A large retrospective analysis showed that those utilizing GLP-1 RAs had a 195% increased risk of major depression, 108% increased risk of anxiety and a 106% increased risk of suicidal behavior [7]. Where the impact on the brain regarding addiction may be beneficial, there is a potential for too much of a good thing. If we influence reward pathways in certain parts of the brain too aggressively, we run the potential risk of mood dysregulation, depression, and even suicidal thoughts.
Other studies on mental health with the use of GLP-1 RAs have found no impact or even improvements, highlighting the unpredictable response [8]. However, the retrospective study referenced above also found a time and dose-dependent relationship. The higher the dosage and the longer it was used, the greater the risk of depression, anxiety and suicidality [9]. A causal relationship is far from established, but given the biological gradient (a necessary factor to determine causality), it should certainly prompt caution and further study.
Other, more common side effects should be part of every discussion prior to starting these medications. Nausea, vomiting, diarrhea, constipation, and abdominal pain can occur in up to 20-40% of individuals [10]. Acute pancreatitis, GI obstruction, and cholecystitis are less common but also occur [11-13]. A family history of certain types of cancers are contraindications and should be reviewed prior to initiating use. One recent retrospective analysis found a 10-fold increased risk of thyroid cancer and glandular growth in those using GLP-1 RA medications compared to those taking other diabetic medications. While other studies have not shown a similar correlation to date, it is prudent to proceed with caution given the potential risks [14].
The problem is our frontline medical system does not give the time nor provide the resources to allow physicians to practice in a way that best serves their patients. Informed consent and shared decision-making take time. If you are a typical primary care physician today, you are seeing 20-plus patients in the clinic just to keep the lights on. You are compelled to write the prescription and keep moving. Survival of the fastest.
Even worse, telehealth companies, whose business model is built on up-charging for prescriptions and patient dependency, are even more ethically culpable. How much time do you think such a company asks its providers to educate potential consumers on the risks of usage and long-term consequences? How many minutes of that visit are allocated to shared decision-making and lifestyle interventions to address the root cause? What resources are provided to minimize usage and dependency over time?
But the most disappointing aspect of it all is that it doesn’t have to be this way. When prescribed responsibly, pharmaceuticals can have a life-saving impact on our society. We now have the tools and resources to support individuals using medications as a bridge to health independence rather than a burden they must carry for life.
As a physician and CrossFit affiliate owner, I can’t tell you how many members I have worked with who, after 6-12 months of CrossFit, have greatly decreased, if not completely stopped, their medications. Their providers are shocked. But we are not surprised. We see it every day in the CrossFit affiliate. Fitness leads to health. Health, as we define it, leads to freedom, autonomy, and self-determination.
Being board-certified in both family and obesity medicine, I utilize GLP-1 RA medications with my patients when indicated. However, I cannot think of one who is not doing CrossFit. Why? Because when you take the time to provide informed consent, everyone is on board with attacking the root cause. And there is no better intervention than CrossFit. It allows medications to be used as an adjunctive therapy. CrossFit addresses the root cause while minimizing the side effects of medication usage at the same time. The foundation of our methodology preaches adequate, high-quality protein intake. This is paramount to preserving skeletal muscle mass through a weight-loss journey. And while our nutrition prescription provides the substrate for muscle retention and growth, it does little without the stimulus. Lifting heavy things should be a necessary component of a comprehensive metabolic health protocol. It helps minimize sarcopenic obesity and shrinks the metabolic spiral that can occur from an incomplete strategy and dependence on GLP-1 RAs alone [15].
Addressing root causes may be simple, but it certainly is not easy. This is where the CrossFit culture shines, promoting adoption of new fitness and lifestyle habits and helping you sustain them over time. It may be the most underappreciated aspect of the methodology.
In medicine today, we often practice as though prescribing medications is binary in regard to lifestyle change: “Well, you had three months and you could not eat better, so I guess it’s just the meds for you.” It’s not medication OR lifestyle interventions, but it may be lifestyle programming AND medications. In a perfect world, pharmaceuticals can be used when necessary as a temporary tool to address significant risk factors until the benefits of lifestyle change can, in turn, result in decreased necessity of medications over time. Often, but not always, these can be removed altogether. Why should this not be our stated goal from the beginning? This is not a sea change or paradigm shift; it is simply a commitment to adhering to our guidelines and established best practices as written.
GLP-1s have shown themselves to be extremely effective medications. But without the education and support to learn how to train, fuel, and recover in a sustainable way, you have only replaced one dependency with another. They should not be seen as the lone solution, but rather an adjunctive tool. Would it not make sense for us as clinicians to provide our patients with all the resources and support necessary to optimize outcomes and minimize side effects? Should we not prioritize appropriate nutrition, movement, and habit formation as much as we do pharmaceuticals?
Before CrossFit, there may have been an excuse. As a typical primary provider in our dysfunctional system, how could you ever hope to support all of these lifestyle components in a comprehensive and effective manner? Today, there is no excuse. The next time you pull out your prescription pad for GLP-1 RA, first complete a referral to your local CrossFit affiliate. Give your patient the opportunity to learn, grow, and be the healthiest, most-impactful version of themselves. You can address root causes and the manifestations of disease at the same time; they are not mutually exclusive. We owe our patients the best care plan we can create, and any individual utilizing pharmaceuticals for a lifestyle-driven disease should be given a prescription for CrossFit, as well.
CrossFit is not in the business of demonizing those who need our support most. Our tent is open, and everyone is invited. We are, however, in the business of keeping it real, and the best, most complete answers do not rely on injections alone. Our approach is for anyone, and it is infinitely scalable. In fact, those who are the most deconditioned get the biggest benefit. You don’t have to do anything except show up and give it your all.
See you at the whiteboard.
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