In my 40+ years as an obesity medicine physician specialist, my entire counseling philosophy and weight management program approach have been rooted in behavior change research related to diet, physical activity, sleep, stress and body image.
Obesity medication and bariatric surgery were prescribed as an adjunct to lifestyle counseling.
This traditional paradigm is now being challenged as many healthcare professionals are questioning the need for continued behavioral counseling.
Looking at the latest research and data related to patients taking GLP-1 medications, here are my thoughts on best practices:
1-Transition from Intensive to Lower-Intensity Behavioral Counseling
Traditional intensive lifestyle intervention programs that included ≥14 in-person visits with a healthcare professional for 6 months is being challenged and for good reason.
Research studies of GLP-1 medications have demonstrated average weight losses of 15% to 21% along with improvements in health when combined with less intensive lifestyle intervention.
Very little additional weight loss or further benefits in health parameters are achieved when intensive lifestyle treatment is used instead.
I recommend lifestyle modification behavioral counseling and patient touch points during:
- Patient evaluation and initiation of GLP-1 therapy
- At dose escalation
- Throughout care as needed for best outcomes, safety monitoring, and referrals to registered dietitian nutritionists, health psychologists and exercise specialists when indicated
During dose escalation especially, regular touch points through telehealth or medical record messaging, can help to reduce the likelihood of patients stopping GLP-1’s due to intolerable side effects.
2-Transition from Counseling on Diet and Exercise Quantity to Diet and Exercise Quality
GLP-1 medications commonly reduce hunger, increase satiation (fullness terminating a meal), and reduce food cravings (desire to eat specific foods) and food noise (persistent unwanted thoughts about food).
Rather than focusing on caloric restriction, dietary recommendations can now shift to:
- Dietary counseling to promote healthy balanced dietary patterns that prioritize nutrient dense and high-quality protein foods, keeping well hydrated, and limiting high-fat, fried, spicy and sugary foods to reduce nausea, a common GLP-1 adverse effect.
- Consuming smaller planned meals, eating slowly, limiting alcohol and carbonated beverages that can also lessen adverse gastro-intestinal side effects.
Rather than focusing only on burning more calories to lose weight, exercise recommendations can shift to:
- Improving cardiovascular health, insulin sensitivity, muscle and bone health, and quality of life.
- Engaging in ≥150 minutes/week of moderate intensity aerobic activity (such as brisk walking), in addition to two or more sessions/week of resistance or strength training targeting major muscle groups such as quadriceps and hamstring muscles is important for all users of GLP-1 medications.
3-Sharpen Obesity Care Counseling Skills
The field of obesity care is rapidly changing as healthcare professionals with varied backgrounds are prescribing new GLP-1 medications and questioning the need for continued lifestyle modification counseling.
To learn more about this topic, here are some resources:
- Read my JAMA Insights invited perspective, Lifestyle modification and Incretin-Based Therapy for Obesity, just published online
- Listen to my short, just-released JAMA Clinical Reviews interview on Diet and Exercise Recommendations for Patients Taking GLP-1 Agonists
- Read our American Diabetes Association Standards of Care article on Pharmacologic Treatment of Obesity in Adults
- Healthcare professionals interested in improving counseling skills for patients with overweight and obesity, can check out my latest book for clinicians, Patient-Centered Weight Management.
RK
Robert Kushner, MD
