At a diabetes conference in Milan, Danish researchers presented evidence that the boundaries defining who qualifies for GLP-1 heart-protective drugs may not align with the actual biology of cardiovascular risk. Analyzing over 313,000 people across two long-running studies, the team found that overweight individuals with BMIs just below the current eligibility threshold face nearly identical heart disease risk to those who qualify — provided they carry elevated remnant cholesterol or signs of chronic inflammation. The study does not demand a policy change, but it asks medicine to reckon with a
Danish study argues for expanding GLP-1 drug eligibility to protect heart health in overweight adults
They had a similar risk of coronary heart disease as those who were eligible
Mark
So the study is saying that roughly half of people with a BMI between 25 and 26.9 have the same heart disease risk as people who already qualify for these drugs. That's the core finding?
Mimi
Exactly. They tracked over 300,000 people for more than a decade and found that overweight people with high remnant cholesterol or inflammation faced 41 to 47 percent increased cardiovascular risk—the same ballpark as people currently eligible for GLP-1s. Yet the rules exclude them.
Luke
But here's the thing—the study shows correlation, not causation. They're saying these excluded people have the same risk profile, but they haven't actually tested whether giving them GLP-1 drugs would prevent heart attacks. That's why the researchers themselves called for clinical trials.
Mimi
Right, and that's important. The study is an observational analysis of existing data. It's making the case that these people *should* be studied in a trial, not that we know for certain the drugs will help them.
Mark
What about the people in that BMI range who don't have elevated cholesterol or inflammation? The study says about half do, which means about half don't.
Mimi
Good catch. The researchers are specifically arguing for expanding eligibility to the half with those risk markers—not blanket access to everyone in that BMI range. It's a targeted expansion based on specific biomarkers.
Luke
And we should note: this is a Danish analysis of UK and Danish populations. The findings might not translate the same way to other countries or ethnic groups. That's another reason why clinical trials matter.
Mark
So the practical next step is: someone runs a trial, gives some of these excluded people the drugs, and measures whether they actually have fewer heart attacks?
Mimi
That's exactly it. The researchers have shown the risk is there. Now they need to show the treatment works for this specific group.
Luke
And there's also the question of cost and access. These drugs are expensive and in high demand. Expanding eligibility would put pressure on supply and raise questions about who pays. The medical case is one thing; the practical implementation is another.
The Pulse
- Millions of overweight people are locked out of GLP-1 drugs by a BMI cutoff that may have no meaningful basis in their actual cardiovascular danger.
- A decade-long analysis of 313,145 people revealed that excluded individuals with high remnant cholesterol or low-grade inflammation face a 41–47% elevated heart disease risk — nearly identical to those the drugs are already approved to treat.
- The gap is not small: roughly half of all people in the excluded BMI range carry these risk markers, representing a potentially vast population denied preventive treatment.
- Researchers stopped short of calling for immediate policy change, instead urging clinical trials to confirm whether extending eligibility would translate into fewer heart attacks and strokes at scale.
- The findings land as GLP-1 drugs sit at the center of medicine's evolving understanding of weight, metabolism, and who deserves intervention — raising harder questions about how eligibility lines get drawn and who they quietly leave behind.
At a diabetes conference in Milan, Danish researchers presented evidence that the boundaries defining who qualifies for GLP-1 heart-protective drugs may not align with the actual biology of cardiovascular risk. Analyzing over 313,000 people across two long-running studies, the team found that overweight individuals with BMIs just below the current eligibility threshold face nearly identical heart disease risk to those who qualify — provided they carry elevated remnant cholesterol or signs of chronic inflammation. The study does not demand a policy change, but it asks medicine to reckon with a quiet inconsistency: that the lines we draw around access to care do not always follow the contours of human vulnerability.
At a diabetes conference in Milan, Danish researchers made a case that could reshape access to some of the most widely discussed drugs in modern medicine. Led by Dr. Karen Hvid of Copenhagen University Hospital, the team asked a pointed question: does the BMI threshold that determines who qualifies for GLP-1 drugs actually reflect who is at risk?
Current approvals cover adults with a BMI of 30 or higher, or 27 and above with weight-related conditions. People with a BMI between 25 and 26.9 — overweight but not obese — fall entirely outside these criteria. To test whether that boundary made medical sense, the researchers analyzed data from 313,145 participants across the UK Biobank and the Copenhagen General Population Study, following them for up to 18 years. Over that period, more than 23,000 developed coronary heart disease or suffered a cardiovascular event.
The critical finding emerged when the team examined the excluded group more closely. About half of those with BMIs in the 25–26.9 range had either elevated remnant cholesterol — a less familiar but potent driver of arterial disease — or markers of chronic low-grade inflammation. These individuals were 41 to 47 percent more likely to develop heart disease than those without such markers. That figure nearly matched the 35 to 41 percent elevated risk seen in people who already qualify for the drugs.
In other words, the excluded group with these specific biological signals faced the same cardiovascular danger as the included group — yet had no access to medications known to lower cholesterol, reduce inflammation, and prevent heart attacks. Dr. Hvid noted that roughly half of all overweight people in this BMI range carry these markers, suggesting the gap in eligibility affects a substantial population globally.
The researchers did not call for immediate policy changes. Instead, they urged clinical trials to determine whether extending GLP-1 eligibility to this group would actually prevent cardiovascular events at scale. The study arrives as these drugs have become central to how medicine thinks about weight and metabolic health — and as questions grow about whether the rules governing access to expensive treatments are keeping pace with what the science is revealing about risk.
At the annual diabetes conference in Milan this week, Danish researchers presented an argument that could reshape who gets access to some of the most sought-after drugs in medicine. The case rests on a simple observation: millions of overweight people who don't currently qualify for GLP-1 receptor agonists face the same heart disease risk as those who do.
GLP-1 drugs like semaglutide and tirzepatide are now approved for weight loss in adults with a BMI of 30 or higher, or a BMI of 27 or above if they also have conditions like high blood pressure, high cholesterol, type 2 diabetes, or a history of heart disease. But there's a gap. People with a BMI between 25 and 26.9—technically overweight but not obese—fall outside these criteria entirely. The Danish team, led by Dr. Karen Hvid at Copenhagen University Hospital, wanted to know whether that boundary made medical sense.
They analyzed data from 313,145 people tracked over more than a decade in two large studies: the UK Biobank and the Copenhagen General Population Study. The participants, with a median age of 58 and roughly half female, all started without coronary heart disease or diabetes. Over the follow-up period—up to 18 years in one study, 15 in the other—23,134 of them developed coronary heart disease, suffered a heart attack, underwent artery-opening procedures, or died from cardiovascular causes.
About two-thirds of the group qualified for GLP-1 drugs under current rules. The rest, more than 90 percent of them, had a BMI in that excluded 25-26.9 range. But here's where the analysis shifted the picture: roughly half of those excluded people had either elevated remnant cholesterol—the cholesterol particles that aren't the familiar HDL or LDL types—or signs of chronic low-grade inflammation. Both are known to drive heart disease risk.
When the researchers compared heart disease outcomes, the numbers aligned in an unexpected way. People in the excluded group who had high remnant cholesterol and low-grade inflammation were 41 to 47 percent more likely to develop heart disease than those without these markers. That increase matched almost exactly the 35 to 41 percent increased risk seen in people who currently qualify for the drugs. In other words, the excluded group with these specific risk factors faced the same cardiovascular danger as the included group—yet received no access to medications known to lower cholesterol, reduce inflammation, and prevent heart attacks and strokes.
Dr. Hvid framed the implication plainly: roughly half of all overweight people with a BMI of 25-26.9 carry these elevated risk markers. They have the disease risk to justify treatment, but the current eligibility rules leave them out. The study makes a case for expanding access, though the researchers stopped short of demanding it. They called instead for clinical trials—the next step needed to prove that prescribing these drugs to this population would actually prevent heart attacks and strokes at scale.
The finding arrives at a moment when GLP-1 drugs have become central to how medicine thinks about weight and metabolic health. Expanding eligibility would affect millions of people globally. But it also raises questions about how we draw lines around who gets access to expensive medications, and whether those lines should be redrawn when the evidence suggests they don't match the underlying biology of risk.
Notable Quotes
About half of people with a BMI of 25-26.9 had levels of cholesterol and/or inflammation that increased their risk of heart problems, and they had a similar risk of coronary heart disease as those who were eligible for GLP-1 drugs—but would not be prescribed them.— Dr. Karen Hvid, Copenhagen University Hospital
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