Post

How to get URL link on X (Twitter) App

On the Twitter thread, click on or icon on the bottom
Click again on or Share Via icon
Click on Copy Link to Tweet
Paste it above and click "Unroll Thread"!
More info at Twitter Help

Michael Albert, MD

Jul 4 • 8 tweets • 2 min read • Read on X

Scrolly

A triple-agonist just posted 30% weight loss at two years. Surgical-magnitude, from a once-weekly shot.

And I'm convinced it's the least important thing that happened to obesity medicine this year. Here's why the biggest number stopped being the story. 🧵

1/ For three years, we ranked these drugs like a leaderboard:
Semaglutide: ~15%.
Tirzepatide: ~21%.
Then retatrutide crossed 28%.

Every year, a bigger number.
We got very good at asking one question: how much weight comes off? That's now the wrong question.

2/ What actually changed in 2026: the class now pulls four different levers.
🔹GLP-1: eat less, ⬇️ inflammation, ⬇️ glucose
🔹GIP: tolerate more, sharpen insulin response
🔹Glucagon: burn more, clear liver fat
🔹Amylin: eat less through a separate circuit, ⬆️ leptin sensitivity

3/ Retatrutide's pivotal trial, TRIUMPH-1: 28.3% at 80 weeks, up to 30.3% at two years in severe obesity. 45% of patients crossed 30% loss.

That's the glucagon lever partly at work. It doesn't just quiet appetite. It tells the body to burn.

4/ But the most important approval of the year wasn't the strongest drug. It was a pill.
Orforglipron: the first non-peptide oral GLP-1. Only ~11-12% weight loss. No needle, no fasting, no cold chain.

It's not competing on the leaderboard. It's competing on the front door.

5/ Then the twist most clinicians are underrating: the liver.

Glucagon drugs treat steatohepatitis directly. Survodutide improved MASH in 62% of patients vs 14% on placebo.

These are starting to look like liver drugs that happen to cause weight loss.

6/ Not every bet paid off. CagriSema, the big amylin combo, lost a head-to-head to tirzepatide: 23% vs 25.5%.
Stacking pathways doesn't automatically win.
So the job quietly changed: from "prescribe the strongest" to "match the mechanism to the patient."

7/ The patient who needs 10% to reverse prediabetes and the one who needs 25% to get off CPAP no longer get the same prescription. They never should have. The best news in obesity medicine is that it finally got complicated: substance-over-noise.beehiiv.com/p/obesity-medi…

• • •

Missing some Tweet in this thread? You can try to force a refresh

This Thread may be Removed Anytime!

Twitter may remove this content at anytime! Save it as PDF for later use!

More from @MichaelAlbertMD

Michael Albert, MD

@MichaelAlbertMD

Jun 29

My patient lost almost no weight on semaglutide. His liver healed. His blood pressure dropped. His sleep apnea lifted. His knees stopped hurting. He barely moved the scale and got better everywhere else.

I'd been measuring the wrong thing for years. 🧵

1/ My patient Marcus came to me to lose weight. A year on semaglutide, he'd lost under 5%.

By my specialty's scoreboard: a non-responder. Then I looked at the rest of his chart.

2/ A1c: normal.
Liver enzymes, elevated for years: normal. Blood pressure: down.
The snoring his wife complained about: gone. His knees on the stairs: better.
He lost only a modest amount of weight, but almost every marker of his health improved. anyway.

Read 9 tweets

Michael Albert, MD

@MichaelAlbertMD

May 19

A patient asked me this week if they could stop their obesity medication.

I told them what the data says:
67% of people who stop regain almost everything within a year.

That's not a failure of willpower. That's biology. And we finally have trials that prove it.

1/ ECO 2026 just changed the conversation in obesity medicine. For 3 years, every major meeting asked: how much weight can we lose? Istanbul asked something different: how do we keep it? Here's what we learned. 🧵

2/ SURMOUNT-MAINTAIN published in The Lancet this week. After losing 22% of their weight on tirzepatide, patients were randomized to continue full dose, drop to 5 mg, or switch to placebo. The results were unambiguous.

Read 9 tweets

Michael Albert, MD

@MichaelAlbertMD

May 11

1/ I'm a physician.
I just left traditional healthcare.

2/ I spent years inside the system.
7-minute visits.
Portal messages answered three days later by someone the patient had never met.

Care fragmented across platforms built around billing codes — not people.

3/ I'm not sure there's any going back.

Last week, I joined Vineyard as Chief Medical Officer and Staff Physician.

It's a direct-care virtual cardiometabolic clinic operating in all 50 states.

No insurance gatekeeping. Built around the patient and physician experience.

Read 7 tweets

Michael Albert, MD

@MichaelAlbertMD

Apr 8

Every morning I take five things.
A statin. Ezetimibe. Psyllium. Creatine. A multivitamin.

Once a week, I add a sixth: tirzepatide.

No rapamycin. No NMN. No Bryan Johnson protocol.

Here's what the evidence actually says—and why I left everything else out. 🧵

1/ Every morning I take five things.
A statin. Ezetimibe. Psyllium. Creatine. A multivitamin.

Once a week, I add a sixth: tirzepatide.
I used to raise an eyebrow at longevity stacks. Then I realized I'd quietly built one—each addition requiring enough evidence to clear the same bar I hold my prescriptions to.

2/ The plaque that ruptures at 62 was building in the third decade or earlier.

Ference et al. (JACC 2015): Mendelian randomization shows lifetime LDL exposure reduction yields ~3× greater CV risk reduction than RCTs achieving equivalent LDL lowering.

My LDL in 2018: 127. Today: 41.
The compounding logic means earlier is disproportionately better.

Read 9 tweets

Michael Albert, MD

@MichaelAlbertMD

Apr 4

I'm 36. I'm a physician. I take a statin—and ezetimibe—every day.

No symptoms. No cardiac history. Just an honest read of the evidence.

Here's what I found—and why I stopped waiting for a reason to act.

1/ I take a statin and ezetimibe every day.
My LDL in 2018: 127 mg/dL.
My LDL today: 41 mg/dL.

Here's exactly what changed — and why the evidence earned my confidence.🧵

2/ The CTT Collaboration pooled 27 RCTs and 170,000+ patients.
Each 1 mmol/L drop in LDL → ~21% relative reduction in major vascular events.

Even in low-risk people. Even in people who "seem fine."

That's not a secondary prevention story. That's a primary prevention story.

Read 9 tweets

Michael Albert, MD

@MichaelAlbertMD

Apr 1

The cholesterol wars are over.

LDL won.

New guidelines. Four landmark trials. An oral PCSK9 inhibitor that matches injectables. And data proving we should be treating patients we currently aren't.

Here's everything clinicians need to know. 🧵

1/ The 2026 ACC/AHA Guideline just retired 10-year-old guidance and brought back something crucial: explicit LDL-C numeric targets.

Not "treat to benefit." Treat to a number.

<55 mg/dL for most established ASCVD. <70 for high-risk primary prevention.

Eleven societies signed off.

2/ Ez-PAVE just answered a question cardiology has avoided for years:

Is <55 mg/dL actually BETTER than <70 mg/dL in secondary prevention?

3,048 patients. Head-to-head RCT. The answer:

10 mg/dL difference in achieved LDL → 33% reduction in MACE. NNT ~32 over 3 years.

For a target adjustment.

Read 9 tweets

Support us! We are indie developers!

This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3/month or $30/year) and get exclusive features!

Become Premium

Don't want to be a Premium member but still want to support us?

Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal

Or Donate anonymously using crypto!

Ethereum

0xfe58350B80634f60Fa6Dc149a72b4DFbc17D341E copy

Bitcoin

3ATGMxNzCUFzxpMCHL5sWSt4DVtS8UqXpi copy

Thank you for your support!

Share this page!

Enter URL or ID to Unroll

Michael Albert, MD

Try unrolling a thread yourself!

More from @MichaelAlbertMD

Michael Albert, MD

Michael Albert, MD

Michael Albert, MD

Michael Albert, MD

Michael Albert, MD

Michael Albert, MD

Did Thread Reader help you today?

Don't want to be a Premium member but still want to support us?

Send Email!