---
type: musing
domain: health
session: 20
date: 2026-04-08
status: active
---

# Research Session 20 — GLP-1 Adherence Trajectory & The Continuous-Treatment Paradox

## Research Question

Is GLP-1 adherence failing at the predicted rate (20-30% annual dropout), and what interventions are changing the trajectory? Does new real-world cardiovascular data show earlier-than-expected population-level signal?

## Belief Targeted for Disconfirmation

**Belief 1: Healthspan is civilization's binding constraint, and we are systematically failing at it in ways that compound.**

The "systematically failing" clause is the disconfirmation target. Specifically: if GLP-1 adherence programs are substantially improving persistence AND real-world cardiovascular signal is appearing earlier than projected (2045 horizon), the failure mode may be self-correcting — which would weaken Belief 1's "systematic" framing.

## What I Searched For

- GLP-1 year-1 persistence rates over time (2021-2024)
- Long-term persistence (2-3 year) data
- Digital behavioral support programs improving adherence
- Real-world cardiovascular mortality signal (SCORE, STEER studies)
- Metabolic rebound after GLP-1 discontinuation
- Heart failure trends (continuing CVD bifurcation thread)
- OBBBA SNAP cuts implementation timeline
- Clinical AI deskilling empirical evidence

## Key Findings

### 1. GLP-1 Adherence: Year-1 Has Nearly Doubled, But Long-Term Remains Catastrophic

BCBS and Prime Therapeutics data reveals a MAJOR update to my model: 1-year persistence for obesity-indicated GLP-1 products has nearly doubled from 33.2% (2021) to 60.9% (2024 H1). Supply shortage resolution and improved patient management cited.

BUT: 2-year persistence is only 14% (1 in 7 members). 3-year persistence even lower.

This creates a highly specific pattern: GLP-1 adherence is improving dramatically at 1 year, then collapsing. The "improvement" story is real but narrow — it's a Year 1 phenomenon, not a structural fix.

### 2. Metabolic Rebound: GLP-1 Requires Continuous Delivery (Like Food-as-Medicine)

Lancet eClinicalMedicine meta-analysis (2025, 18 RCTs, n=3,771): GLP-1 discontinuation produces:
- 5.63 kg weight regain
- 40%+ of weight regained within 28 weeks of stopping semaglutide
- 50%+ of tirzepatide weight loss rebounds within 52 weeks
- Pre-treatment weight levels predicted to return in <2 years
- Cardiovascular markers (BP, lipids, glucose) also reverse

CLAIM CANDIDATE: "GLP-1 pharmacotherapy follows a continuous-treatment model: benefits are maintained only during active administration and reverse within 1-2 years of cessation — requiring permanent subsidized access infrastructure rather than one-time treatment cycles."

This DIRECTLY PARALLELS Session 17's food-as-medicine finding: food-as-medicine BP gains fully reverted 6 months after program ended. The pattern generalizes across intervention types.

### 3. Real-World Cardiovascular Signal: Strong But Selection-Biased

SCORE study (2025): Semaglutide 2.4mg in ASCVD + overweight/obese patients (no diabetes). Over mean 200 days follow-up: 57% reduction in rMACE-3, significant reductions in CVD mortality and HF hospitalization.

STEER study (2026): Semaglutide vs tirzepatide in 10,625 matched ASCVD patients — semaglutide showed 29-43% lower MACE than tirzepatide. Counterintuitive — tirzepatide is superior for weight loss but semaglutide appears superior for CV outcomes. May reflect GLP-1 receptor-specific cardiac mechanisms independent of weight.

CRITICAL CAVEAT: Both studies in high-risk ASCVD patients with established disease. This is NOT the general population. The earlier-than-expected CV signal exists — but only in high-risk, high-access patients already on treatment.

GLP-1 + HFpEF (pooled analysis of SELECT, FLOW, STEP-HFpEF): 40%+ reduction in hospitalization/mortality in HFpEF patients. This matters because HFpEF is the specific failure mode driving the all-time high HF mortality rate I identified in Session 19.

### 4. CVD Bifurcation Confirmed Again: JACC Stats 2026

JACC January 2026 inaugural report: "Long-term gains in mortality are slowing or reversing across cardiovascular conditions." Hypertension-related CV deaths nearly DOUBLED from 2000 to 2019 (23→43/100k). Treatment and control rates stagnant for 15 years.

HFSA 2024/2025 report: HF rising since 2011, 3% higher than 25 years ago, projected to reach 11.4M by 2050 from current 6.7M. Black mortality rising fastest.

This is the third independent confirmation of the CVD bifurcation pattern (Session 19, JACC Stats 2026, HFSA 2024/2025). At this point this is a CLAIM CANDIDATE with strong support.

### 5. Digital + GLP-1 Programs: Half the Drug, Same Outcomes

Danish cohort (referenced in HealthVerity analysis): Online behavioral support + individualized semaglutide dosing → 16.7% weight loss at 64 weeks with HALF the typical drug dose. Matches full-dose clinical trial outcomes.

BUT: New safety signal emerging. Large cohort study (n=461,382 GLP-1 users): 12.7% nutritional deficiency diagnosis at 6 months; vitamin D deficiency at 13.6% by 12 months. Iron, B vitamins, calcium, selenium, zinc deficiencies rising.

This is an underappreciated safety signal. GLP-1s suppress appetite broadly, not just fat — they're creating micronutrient gaps that compound over time. New claim territory.

### 6. OBBBA SNAP Cuts: Already In Effect, Largest in History

$186 billion SNAP cut through 2034 — largest in history. 1M+ at risk in 2026 from work requirements alone. States implementing beginning December 1, 2025. 2.4M could lose benefits by 2034.

States' costs projected to rise $15B annually once phased in — which may force further state cuts.

This intersects with the SNAP→CVD mortality Khatana thread. The access contraction is happening simultaneously with evidence that continuous access is required for intervention benefits.

### 7. Clinical AI Deskilling: Now Has Empirical RCT Evidence

Previously theoretical. Now documented:
- Colonoscopy multicenter RCT: Adenoma detection rate dropped 28.4% → 22.4% when endoscopists reverted to non-AI after repeated AI use
- Radiology: Erroneous AI prompts increased false-positive recalls by up to 12% among experienced readers
- Computational pathology: 30%+ of participants reversed correct initial diagnoses when exposed to incorrect AI suggestions under time constraints

This moves deskilling from claim-by-mechanism to claim-by-evidence. These are the first RCT-level demonstrations that AI-assisted practice impairs unassisted practice.

## Disconfirmation Result

**Belief 1 NOT DISCONFIRMED — but the mechanism is more precisely specified.**

The "systematically failing" claim holds. The apparent improvement in GLP-1 year-1 adherence does NOT constitute systemic correction because:
1. Long-term (2-year) persistence remains catastrophic (14%)
2. Metabolic rebound requires permanent continuous delivery
3. Access infrastructure (Medicaid, SNAP) is being cut simultaneously
4. Real-world CV signal exists but only in high-access, high-risk patients

The failure is structural and self-reinforcing: the interventions that work require continuous support, and the political system is cutting continuous support. This is the same pattern as food-as-medicine.

## Cross-Domain Connections

FLAG @Rio: GLP-1 continuous-treatment model creates a permanent-demand financial architecture. This is not like statins (cheap, daily, forgotten) — it's more like insulin (specialty drug, monitoring, behavioral support). Living Capital thesis should price this differently.

FLAG @Theseus: Clinical AI deskilling now has RCT evidence (colonoscopy ADR, radiology false positives). The human-in-the-loop degradation claim I have in the KB (from mechanism reasoning) is now empirically supported. Update confidence?

FLAG @Clay: The SNAP cuts + food-as-medicine reversion + GLP-1 rebound pattern represents a narrative about "interventions that work when you keep doing them, but we keep defunding them." This has a specific storytelling structure worth developing.

## Follow-up Directions

### Active Threads (continue next session)
- **GLP-1 + HFpEF specific mechanism**: Semaglutide reduces HF hospitalization in HFpEF patients by 40%+. But HFpEF is at all-time high. What's the math? Is GLP-1 scaling fast enough to offset the rising tide of HFpEF? Look for prevalence data on GLP-1 use in HFpEF patients vs total HFpEF population.
- **STEER study counterintuitive finding**: Semaglutide > tirzepatide for CV outcomes despite tirzepatide being superior for weight loss. Suggests GLP-1 receptor-specific cardiac mechanism (not just weight). Search for mechanistic explanation — GIPR vs GLP-1R cardiac effects.
- **GLP-1 nutritional deficiency**: 12.7% at 6 months is substantial. Search for which deficiencies are most clinically significant and what monitoring/supplementation protocols are being developed. AHA/ACLM joint advisory on nutritional priorities came up — read that.
- **Clinical AI deskilling interventions**: Evidence shows mitigation is possible with "skill-preserving workflows." What do these look like? Has any health system implemented them at scale?

### Dead Ends (don't re-run these)
- **"JACC Khatana SNAP county CVD" specific study**: Multiple searches haven't surfaced the specific full paper from Session 19's follow-up. Try searching PubMed directly for Khatana + SNAP + CVD + 2025 with exact author name.
- **"Kentucky MTM peer review status"**: No update found in this session. The study was cited but hasn't appeared to clear peer review as of April 2026.

### Branching Points (one finding opened multiple directions)
- **Continuous-treatment model pattern**: Applies to food-as-medicine (Session 17 reversion finding) AND GLP-1 (Session 20 rebound finding). This generalization is worth formalizing as a claim. Direction A: push this as a domain-level claim about behavioral/pharmacological interventions; Direction B: let it develop through one more session of confirming the pattern in behavioral health (antidepressants, SSRIs, and discontinuation syndrome?). Pursue Direction A — the food/GLP-1 convergence is already strong.
- **SNAP cuts + metabolic cascade**: $186B cut to food assistance happening at the same time as GLP-1 metabolic rebound proving caloric adequacy matters for weight maintenance. Direction A: CVD mortality projection (Khatana-style analysis of OBBBA SNAP impact on CVD). Direction B: micronutrient angle (SNAP provides macros, GLP-1 users lose micros — double deficiency in food-insecure GLP-1 users). Direction B is novel and underexplored — pursue it.
