The right GLP-1 dose has to be measured, not one size fits all

METABOLIC HEALTH · OCTOBER 2026

The right GLP-1 dose has to be measured and personalised to the person taking it.

The standard protocol gives very different people the same drug on the same schedule. I think the dose should start from the person, and that means measuring before the first injection.

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THE PROBLEM

The usual way to start a GLP-1 is a fixed starting dose, roughly doubled every four weeks over about 16 weeks. The schedule is the same for a lean man who trains five days a week and for someone with a lot of weight to lose. That is how most of pharma works, one size fits all, and GLP-1s are the clearest example of it right now.

A lot of what gets sold as "microdosing" is not much different. Many clinics and pharmacies start at the standard dose and double it on the same timetable. That is standard low dosing with a new label. Microdosing worth the name starts at a fifth to a tenth of the standard starting dose and adjusts from there.

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WHY IT MATTERS

With these drugs there is not much room between enough and too much. For most people the goal should be appetite control, where the food noise goes quiet and eating is still something you enjoy. Push past that into appetite suppression and people stop eating properly. If they are not getting enough protein and lifting, they lose muscle along with the fat.

A dose that is too high shows up in other ways. Mood can go flat. Some people see their heart rate climb, their heart rate variability drop and their sleep get worse, even on small doses. Others, especially people who are metabolically unwell, need a higher dose before they see any benefit.

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HOW I THINK ABOUT THIS

Measure first, then set the dose from what you find, and keep measuring. Before the first injection that means a proper baseline: fasting insulin, HbA1c, C-reactive protein, a blood count, liver and kidney function, lipids, thyroid and sex hormones, and body composition from a DEXA scan. Then run the same markers again during treatment, because labs can move before the weight does. If I could only keep one, it would be fasting insulin.

This is the problem we work on at Expand Health: turning labs, tests and clinician notes into one record and a plan for one specific person.

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WHAT YOU CAN DO WITH THIS

• — Get a baseline before you start: fasting insulin, HbA1c, C-reactive protein, a metabolic panel and lipids at minimum. Without it there is nothing to compare against later.
• — If you are already on one, ask your prescriber whether the dose was chosen for your body and your goals, or whether it just followed the titration chart.
• — Protect your muscle while you are on it. Eat more protein and train your lower body with progressive overload.
• — Know the signs of too much: food has lost all appeal, your mood has gone flat, your sleep or heart rate variability has got worse. Any of those is a reason to talk to your doctor about the dose.

THE BIGGER PICTURE

Stopping matters too. In the follow up to the STEP 1 semaglutide trial, people regained about two thirds of the weight within a year of coming off, and the cardiometabolic gains drifted back toward baseline. Some people will need these drugs long term and some may be able to come off. The only way to know which group you are in is to keep measuring.

None of this is medical advice. Talk to your doctor before you start or change a dose.

P.S. If you or someone you know is on a GLP-1 right now, I am curious: did anyone measure your baseline labs before the first dose, or did the conversation go straight to the pen? Hit reply and tell me.

— Emilian