The advent of GLP-1 medications has radically changed the conversation about the treatment of obesity. Effective treatments such as semaglutide and tirzepatide have grown in popularity and use, with more agents in the pharmaceutical pipeline. However, the treatment of a chronic illness such as obesity is not based on medication alone, but on changing the lifestyle that helped to create it.
Why Lifestyle Still Matters
While genetics play a role, environmental factors are the primary driver of this epidemic; between 1988 and 2018, obesity rates among adults and children roughly doubled, while severe obesity tripled among adults and more than doubled among children in the US [1,2]. The genetics of the population didn’t necessarily change, but the sedentary lifestyle and prevalence of highly palatable, ultra-processed foods increased during this period.
Judicious use of these medications is documented to result in clinically significant weight loss, in conjunction with a reduced calorie diet and increased physical activity [3,4]. However, it is also clear that individuals often regain this weight and can lose the resultant cardiovascular benefits after stopping these medications [5,6]. Although many obesity specialists cite this as a reason for long-term use of these medications, this points to the essential role of lifestyle changes for maintaining weight loss and improving health.
GLP-1 Medications as a Window for Change
GLP-1 medications are effective for many in reducing food cravings and portion sizes by impacting motility of the gastrointestinal tract as well as affecting brain centers of satiety and pleasure [7]. This time of decreased “food noise” is a golden opportunity to work on not just the amount but the type of food that is being consumed. Transitioning away from the calorie-dense, ultra-processed, highly addictive, convenient fast foods to a food plan emphasizing whole plant foods and lean proteins would provide long-term benefits of improving nutrient density while lowering daily calories. The key is sustainability. It’s not just about telling patients to eat more vegetables and exercise, but to work with them individually regarding what specific plant foods and types of physical activity they can enjoy and work into their daily lives in a realistic and doable way. Accordingly, much higher rates of weight loss (14.9%) were achieved with semaglutide in drug trials that included more intensive dietary and physical activity changes [3], compared to more “real world” data which suggested much lower rates of weight loss of about 4.4% [8]. Clearly, the investment of time and effort in working with individuals on specific lifestyle changes is important. As challenging as it is to include this in clinical practice, it is the sustainable long-term lifestyle changes that providers work through with their patients that can potentially have the highest returns on investment.
A Patient-Centered Start to Treatment
As noted in a joint advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association and The Obesity Society [9], the initiation of GLP-1 medications should be approached in a patient-centered and systematic fashion. Patients should have a comprehensive evaluation of their medical history, including conditions that may increase the risk of complications of GLP-1 therapy, so that this can be better accounted for (e.g. GI disorders, sarcopenia, nephrolithiasis). Their current dietary habits should be assessed, including their intake of both healthy and unhealthy foods and beverages, and counseling should be provided, in addition to setting specific goals for dietary change to improve overall health and efficacy of weight loss with this treatment. Evaluation of other aspects of lifestyle, including the regularity and intensity of physical activity, adequacy and quality of sleep, stress reduction, social connection, and the use of toxic substances should be addressed.
In order to make these changes sustainable, dietary preferences and social determinants of health need to be accounted for. To enhance medication adherence, clinicians need to manage side effects, including gastrointestinal problems, potential nutrient deficiencies, and prevention of muscle and bone loss. Ultimately, the message should not be medication focused, but lifestyle focused, with medication being a useful tool in assisting with lifestyle change.
Physical Activity and Muscle Preservation
The importance of physical activity, both aerobic and resistance activities, cannot be overstated. Decades of research have affirmed the importance of physical activity in cardiovascular and mental health, as well as weight loss and maintenance [10,11]. To maximize clinically significant weight loss, while reducing the loss of lean body mass that occurs with the GLP-1 medications, aerobic and resistance training must be part of the regimen. Aerobic training is most effective at 150 minutes or more of moderate intensity activity per week, with at least 3 days of resistance training [9]. Merely increasing protein intake without coupling it with adequate physical activity can lead to excess calories which will sabotage health and weight loss goals [9].
Addressing the Root Causes
Obesity is ultimately not a GLP-1 medication deficiency, as hyperlipidemia is not a statin-deficiency. Obesity is a disorder that is due in large part to fundamental changes in the types of foods we eat and the sedentary, stressful, sleep-deprived lives we live. There is more complexity to this, and genetics (particularly epigenetics) play a role, but the “epi” of epigenetics points to changes in the environment that impact gene expression. This work on addressing the inherent environmental causes of the obesity epidemic involves lifestyle medicine education of patients and medical providers, policy changes in the food system, and resources to improve population health. If we expect yet another “magic pill” to save the day, we will fall into the fallacy that technology alone will save us. We need to work on the root causes, in addition to developing new medical therapies, because if we do not, history has shown us that the underlying problems not only remain unresolved but sprout yet another complication.
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