I'm not overweight. Should I take semaglutide anyway for cardiac protection?

No, not based on current evidence. The SELECT trial enrolled patients with BMI 27 or above. The evidence for cardiovascular benefit in patients below this threshold does not exist from direct trial data. Extrapolating the SELECT result to lean, normal-weight men is speculative, not evidence-based.

The drugs also carry non-trivial risks and costs in lean individuals: the potential for lean mass loss without the large fat depot to draw from, the chronotropic heart rate effect, the gastrointestinal side effects (nausea, vomiting, constipation), the rare risks of cholecystitis and pancreatitis, and the financial cost of approximately $900–$1,400 per month without insurance coverage. In a lean, fit man whose cardiovascular risk is better addressed through optimized ApoB management, exercise, sleep, and dietary quality, adding semaglutide without an evidence-based indication is not justified by the risk-benefit calculation. The drug earns its place for specific populations. It is not a universal longevity drug for every man over 40. (Lincoff et al., NEJM, 2023)

Cardiologist's calibrated position, Unsupported (5) for semaglutide as a cardiovascular prevention tool in lean, non-diabetic men without established CVD.

What to do: If your BMI is below 27 and you have no prior cardiac events, the cardiovascular case for semaglutide is not established. Invest the same resources in ApoB testing, CAC scoring, and exercise optimization, all of which have strong evidence bases for lean men.

For the full picture, read The Drug That Surprised Cardiologists.