Use of Glucagon-Like Peptide-1 Receptor Agonists by Non-Diabetic Healthcare Workers in Several Countries

This multicounty cross‐sectional study was conducted from September to December 2023. This study was reported following the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [8].

The study was approved by the Institutional Review Board (IRB) in Hamad Medical Corporation (HMC) (Ref number: MRC‐01‐23‐315). The study was conducted in accordance with Helsinki's declaration. Informed consent was obtained from the participants before completing the online survey. Throughout the study, confidentiality of participant data was maintained. As for international collaboration, the participating countries typically adopted one of two approaches: they either accepted the IRB approval from the primary research organization, HMC, or they pursued their own IRB approval process through their respective local or national ethical review committees. The IRB has approved the study at the Applied Science Private University, Jordan (2023‐PHA‐34) and the IRB at King Abdullah Medical City, Saudi Arabia (23‐1162).

We recruited participants from diverse HCPs, including nurses, doctors, and allied health workers, from 10 countries (Egypt, India, Iraq, Jordan, Saudi Arabia, Lebanon, Pakistan, Palestine, the Philippines, and Qatar). For participants to be eligible, they must be HCPs who have recently personal use of GLP‐1RAs for weight management only. Those who declined to participate were excluded from the study.

A convenience sampling strategy was employed. With 657 participants, the study can estimate the prevalence of any type of GLP‐1 among users with a maximum margin of error of ±4% at 95% confidence intervals (CI) based on the Wald Method.

Face validity was established through iterative expert reviews, ensuring the survey items were clear, relevant, and appropriate for assessing our objectives. It consists of two main parts: Section A, an introduction, and a screening section. This section begins with an introductory question to determine whether the respondent has ever used GLP‐1 RAs for weight management. This screening step ensures that only relevant respondents proceed with the survey. If the participant is eligible, he/she completes the demographics and professional background section. We collected demographic information (age, gender, weight, height, HbA1c levels) and the participants' professional background details (educational level, professional role, practicing country). This data helps analyze the responses in the context of the respondents' backgrounds.

Section B‐ the use of GLP‐1 Receptor agonists. This section delves into the specifics of GLP‐1 RAs use utilizing the Likert scale and covering several areas: ▪Indications: Participants are asked about the indications for which they have used GLP‐1 receptor agonists, including weight management in non‐diabetic patients or other off‐label use such as Polycystic Ovary Syndrome (PCOS), pre‐diabetes, and others.▪Doses: This query determines whether the off‐label dose(s) is below, within, or above the recommended range.▪Reasons: Respondents provide their main reasons for using GLP‐1RAs, such as limited treatment options, previous positive experiences, Recommendations from Colleagues/Friends/Relatives, social media advertisements, published literature, and other reasons.▪Safety, Efficacy, and Knowledge: This part assesses perceptions of the safety and efficacy of GLP‐1 RAs use, observed adverse events, and whether there are official guidelines or formal education/training.

We leveraged social media platforms like LinkedIn, X (formerly Twitter), and Facebook professional groups to reach and recruit diverse HCPs from multiple countries. This approach involved designing a post communicated the study's objectives, inviting active participation, and guiding interested individuals to a centralized SharePoint link for further information and enrollment.

The statistical analysis was performed using STATA 17 software (College Station, TX: Stata Corp LP). Data was thoroughly checked and cleaned. Descriptive statistics were employed to summarize the data; Categorical variables were expressed as a percentage (%) and frequencies, while skewed continuous data were expressed as median and interquartile range. Inferential statistics were used to estimate the prevalence of GLP‐1Ras use, prevalence was expressed as a percentage (%) with 95% CI. The participants were categorized based on the WHO's BMI index classification [9]. For a more insightful analysis, we merged the overweight and obese categories into a single group, as detailed in Table 1.

Associations between safety perception and demographic variables, mainly age, sex, education, and BMI categories, were assessed using the Chi‐squared test with Fisher's exact test when expected counts fall below 5. For such analysis, answers to the perception question were recoded into "safe" which included "very safe" and "somewhat safe," "unsafe" which included "very unsafe" and "somewhat unsafe" and "neither" for those who answered, "neither safe nor unsafe" The same analysis was also done for the efficacy perception. All p values reported were two‐sided p‐values. A p value that is lower than 0.05 was considered statistically significant.

This study was funded by the Medical Research Center at HMC (MRC‐01‐23‐315). The funder had no role in the study design, data collection, analysis, interpretation, or report writing.

Our study included 657 healthcare professionals (HCPs), with a higher proportion of female participants (59.2%) compared to males (40.8%). The median BMI was 26.7 (IQR: 23.8−30.7)

The overall median age of participants was 36.0 years (IQR: 29.0–44.0). While there was some age diversity, younger participants (23–44 years) constituted the majority (67.5%), followed by middle‐aged individuals (45–55 years) at 16.0%, with only 5.0% aged 56 years or older. the majority of respondents practice in Egypt (35.8%) and India (28.0%), followed by Pakistan (11.3%), Jordan (9.9%), and Qatar (7.5%). Smaller proportions of respondents reported practicing in KSA (2.1%), Lebanon (2.4%), the Philippines (1.5%), Iraq (0.9%), and Palestine (0.5%).

Nurses represented the largest group, 44.7% (n = 294), of whom 189 held a bachelor's degree, 76 had a master's degree, and 24 held a Ph.D. Physicians comprised 36.2% (n = 238), with 76 holding a bachelor's degree, 140 having a master's degree, and 21 possessing a Ph.D. Allied health professionals accounted for 18.7% (n = 123), including 60 with a bachelor's degree, 34 with a master's degree, and 26 with a Ph.D. Further details are presented in Table 1.

The survey findings presented in Table 2 indicate that Semaglutide was the most frequently used GLP‐1RA, with a prevalence of 45.6% (95% CI: 41.8%–49.5%). Liraglutide was the second most commonly used GLP‐1RA, with a prevalence of 36.9% (95% CI: 33.2%–40.8%).

Dulaglutide and Exenatide were used by 17.0% (95% CI: 14.2%–20.1%) and 14.1% (95% CI: 11.5%–17.0%) of participants, respectively. Lixisenatide had a prevalence of 8.5% (95% CI: 6.5%–10.9%), while Albiglutide had the lowest reported prevalence at 7.0% (95% CI: 5.1%–9.2%).

Regarding the perceived safety of GLP‐1Ras usage, our analysis revealed that 68.6% of participants considered these medications to be safe (41.2% somewhat safe, 27.4% very safe), whereas 14.5% perceived them as unsafe. (12.2% somewhat unsafe, 2.3% very unsafe).

Our analysis found no significant difference in perceived safety by age (p = 0.487), sex (p = 0.729), and by BMI categories (p = 0.089). Notably, a significant statistical association exists between safety perceptions and educational level (p = 0.022). The percentage of participants who perceived the off‐label use of GLP1‐RAs as less safe is significantly higher among participants with more than bachelor's degrees as compared to those with bachelor's degrees or lower (18.3% vs. 10.8%, p = 0.022), Further details are presented in Table 3.

Regarding the perceived efficacy of GLP‐1RA use, 73.5% of participants considered these medications to be effective (46.4% somewhat effective, 27.1% very effective), whereas 11.4% perceived them as ineffective (9.9% somewhat ineffective, 1.5% very ineffective).

The percentage of HCPs who perceived GLP‐1RAs as effective was significantly lower among those aged 56 years and above compared to younger age groups (48.5% vs. 72.0%–79.1%, p = 0.011*) and significantly lower among HCPs with post graduate degree as compared to HCPs with bachelor's degrees or lower (70.0% vs. 76.9%, p = 0.006*), Our analysis found no significant associations between participants perception of efficacy and sex (p = 0.663) or BMI categories (p = 0.446), Further details are presented in Table 4.

41% of participants using GLP‐1RAs were male, reflecting a growing trend of body dissatisfaction among men. This challenges the widely accepted notion that women experience greater body image dissatisfaction due to societal norms and idealized body standards [10].

Emerging evidence suggests that while men often report lower body dissatisfaction in surveys, this may be due to measurement tools predominantly assessing fat‐related concerns, which are traditionally emphasized among women [11]. Instead, male body dissatisfaction is often centered around attaining a leaner, more muscular physique rather than simply weight reduction, diverging from the thin ideal typically associated with female body image concerns.

This does not imply that men are indifferent to their body weight. Instead, their dissatisfaction tends to be more about attaining an idealized form of masculinity, which emphasizes muscularity over simply losing weight.

The majority of participants were young (23–44 years, 68%), which aligns with the growing trend of weight management interest among younger HCPs. Notably, age played a role in the indication for GLP‐1RA use. Younger participants primarily used GLP‐1RAs for weight management (54%), while older HCPs prioritized their use for metabolic conditions such as PCOS and prediabetes. This aligns with existing research indicating that younger individuals are more influenced by aesthetic motivations, whereas older individuals prioritize metabolic health improvements. Moreover, compared to older women, men generally maintain higher levels of self‐esteem in their later years [12].

Our findings indicate a high prevalence of Semaglutide use (46%), which aligns with existing literature [13]. despite its high cost compared to other GLP‐1RAs, one potential driver for high usage could be the availability of Semaglutide in both injectable and oral forms [14, 15], This dual formulation provides convenience for those who prefer oral administration while still accommodating those who opt for the faster onset of action associated with injections. Additionally, practical consideration in dosing may contribute to its high use. Research has shown that once‐weekly dosing of injectable GLP‐1 RAs is associated with better adherence compared to once‐daily dosing, with an 11% lower risk of non‐adherence [15, 16].

Moreover, recent RCTs from the STEP program have consistently demonstrated Semaglutide superiority in promoting weight loss over Liraglutide [17]. On average, Semaglutide users experienced an 11%–14% reduction in body weight, while those using Liraglutide had a 7.8% reduction [17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34]. Additionally, economic evaluations suggest that Semaglutide 2.4 mg is cost‐effective, with a willingness‐to‐pay (WTP) threshold of CAD 50,000 per quality‐adjusted life year (QALY). A QALY is a measure used in health economics to assess the value of medical interventions, incorporating both quality and quantity of life gained. The CAD 50,000 per QALY threshold is widely used in economic evaluations as a benchmark for cost‐effectiveness, indicating that if a treatment provides a year of perfect health for less than this amount, it is considered a good investment for healthcare systems. This reinforces the economic justification for Semaglutide's use, particularly given its superior weight loss efficacy, metabolic benefits, and the potential to reduce obesity‐related complications, which can significantly lower long‐term healthcare costs [35].

Liraglutide was the second most prevalent GLP‐1RA (36.9%) is consistent with its longer market presence and established safety profile. The LEADER trial demonstrated cardiovascular benefits of liraglutide, showing a 13% reduction in major adverse cardiovascular events compared to placebo in patients with type 2 diabetes and high cardiovascular risk [36]. The lower prevalence rates of dulaglutide (17.0%), exenatide (14.1%), lixisenatide (8.5%), and albiglutide (7.0%) may reflect their comparative efficacy profiles or administration considerations. For instance, the once‐weekly administration of dulaglutide offers convenience advantages, but its weight loss effects are generally less pronounced than those of semaglutide.

The preference patterns observed among HCPs to use mostly semaglutide, liraglutide, or dulaglutide may also reflect the influence of recent cardiovascular outcome trials [29, 36, 37] for GLP‐1 RAs with proven cardiovascular benefits [28, 35, 36]. suggesting that cardioprotective effects may be a key consideration in their selection by HCPs.

Our results indicate that HCPs generally hold favorable views toward GLP‐1RAs, with 68.6% considering these medications safe and 73.5% perceiving them as effective. These positive perceptions align with the substantial body of evidence from clinical trials and real‐world studies supporting both the safety profile and therapeutic benefits of GLP‐1Ras [15, 17, 21, 22, 23, 24, 25, 38].

Education level emerged as a significant factor influencing both safety and efficacy perceptions among HCPs. Those with postgraduate qualifications expressed greater concerns about both safety and efficacy compared to those with lower educational attainment. This pattern suggests that advanced education fosters a more critical evaluation of medication benefits and risks, potentially due to greater exposure to scientific literature discussing clinical trial limitations and emerging safety signals. Higher educational levels may enhance critical appraisal skills, leading to more cautious perceptions of medication safety and efficacy. While the direct relationship between academic degree level and perceptions of medication safety and efficacy requires further investigation, our results suggests that educational background significantly influences HCPs' clinical perceptions, confidence, and practices in ways that likely extend to medication‐related judgments [39].

Age was significantly associated with efficacy perceptions (p = 0.011) but not safety perceptions (p = 0.487). HCPs aged 56 years and above were notably less likely to perceive GLP‐1RAs as effective (48.5%) compared to younger age groups (72.0%−79.1%).

Understanding physician perceptions of GLP‐1RAs is indeed important, as significant discrepancies exist between clinical evidence and how HCPs view these medications. For example, physicians reported an average patient weight loss of 9.22% with GLP‐1RAs, which is substantially lower than the 14.9% and 18.5% reported in the STEP and SURMOUNT clinical trials. Similarly, physicians estimated side effect rates at 32.62%, markedly lower than trial‐reported rates of 80%−90% [40].

These perception gaps extend to understanding cardiovascular benefits as well. Only 48.4% of physicians recognized cardiovascular benefits in diabetic patients (consistent with random guessing), and just 39.3% recognized these benefits in non‐diabetic patients. This suggests a significant knowledge deficit regarding the evidence‐based benefits of these medications [40].

Rather than focusing on researching off‐label use itself, which is indeed common practice among HCPs, research should address these gaps in perceptions. The discrepancy between physician perceptions and clinical evidence could impact patient care, medication adherence, and clinical outcomes. Physicians who underestimate efficacy might be less likely to prescribe these medications or may not provide patients with realistic expectations, while underestimating side effects could leave patients unprepared for common adverse events.

this study highlights the growing issue of obesity among HCPs [41], while HCPs have the medical knowledge to self‐prescribe, it is generally recommended that they seek independent medical advice to ensure objective assessment and monitoring. Self‐prescribing, especially for off‐label uses such as weight management, can lead to ethical dilemmas and potential health risks [42]. Therefore, HCPs considering GLP‐1 receptor agonists for personal use should consult with a qualified colleague to discuss the benefits, risks, and appropriate monitoring associated with these medications. Addressing obesity within the healthcare workforce through comprehensive wellness programs and alternative interventions could help reduce reliance on pharmacologic solutions.

Our findings suggest that HCPs are not immune to the same societal pressures influencing the general population regarding body image and weight management [43]. The observed divergence between generally positive perceptions (approximately 70% favorable for both safety and efficacy) and the more cautious views held by specific demographic subgroups (particularly those with advanced education and older groups) warrants further investigation. This pattern could indicate potential knowledge gaps or differing interpretations of available evidence that might influence clinical decision‐making and patient counseling regarding GLP‐1RA therapy. Additionally [39].