November/December 2024 Issue

The Impact of New Weight Loss Drugs on Dietetics
By Carrie Dennett, MPH, RDN
Today’s Dietitian
Vol. 26 No. 9 P. 14

What’s changed for weight-inclusive and weight management dietitians?

It’s been less than four years since the first glucagonlike peptide-1 (GLP-1) receptor agonist medication was approved for use for weight loss. Today, these medications—which include semaglutide (Ozempic and Wegovy), liraglutide (Saxenda), and tirzepatide (Mounjaro and Zepbound)—are an inescapable part of public discourse. But how are they impacting dietetics practice? Today’s Dietitian talked to weight-inclusive dietitians, weight-management dietitians, and those who are somewhere in between.

Julia Lloyd, MPH, RD, LDN, CDCES, senior dietitian for the Center for Weight Management and Wellness at Brigham and Women’s Hospital in Boston, says the surge in GLP-1 use is continually changing the weight management landscape. For example, she says many of her patients are opting to try one of the new weight loss medications before considering surgery, often due to a perception that surgery will result in complications.

Clara Nosek, MS, RD, an outpatient dietitian in Modesto, California, says she began seeing an immediate uptick in patients prescribed GLP-1s for weight loss when they became approved for that use. “Prior to that, my days were a couple GLP-1 counseling sessions, and mostly diabetes and MNT. Now my schedule is 85% weight management.” However, she says many of her patients are referred for weight loss when the real issue is often that they have a lack of knowledge about how to manage their health condition.

Not every person who is taking a GLP-1 medication for weight loss consults with a dietitian, but for those who do, many are also open to making diet and lifestyle changes. Lauren Harris-Pincus, MS, RDN, Basking Ridge, New Jersey-based founder of NutritionStarringYOU.com and nutrition advisor for Ro, which prescribes GLP-1s, says she finds that her clients taking a GLP-1 are more capable of adopting positive diet and lifestyle habits because they’re no longer experiencing uncontrollable hunger and food noise. “The GLP-1s remove obstacles. They’re a phenomenal tool for the right person.”

Food Noise and Food Relationships
Quieting “food noise” is one commonly cited benefit of GLP-1s,1,2 although not all dietitians agree about what that means. Colleen Tewksbury, PhD, RD, CSOWM, an assistant professor of nutrition at Penn Nursing in Philadelphia, describes it as, “They no longer feel as though their body is screaming at them to eat or crave higher calorie foods, nor do they find themselves constantly thinking about food, all of which are common reports in behavioral weight loss.”

Melissa Majumdar, MS, RD, CSOWM, LDN, metabolic and bariatric coordinator at Emory Healthcare in Atlanta, says many of her patients have a challenging relationship with food and their bodies, and regulating hunger can take the pressure off food decisions. “Weight loss is one of the more challenging goals we can embark on, and using tools that can support efforts just makes sense,” she says.

Lloyd says one patient told her, “‘I no longer feel like a prisoner in my own mind.’ Previously, food was constantly at the forefront of their mind due to insatiable hunger or obsessive worry that a meal or food would lead to weight gain.”

On the flip side, Abby Chan, MS, RDN, RYT, co-owner and nutrition director of EVOLVE Flagstaff in Arizona, says food noise also decreases when dietitians help clients eat enough food, then create more permission around these foods. She says using GLP-1s to reduce hunger and appetite can give people false confidence that they’ve healed their relationship with food, even without the medication. “Once they do get off, it becomes this tidal wave back into the out-of-control feeling around food, feeling like it’s always on your mind, and feeling hungry all the time,” she says, noting that some of this is due to the body’s response to caloric restriction while on the drug.

Kimmie Singh, MS, RD, owner of Body Honor Nutrition in New York City, has worked with several clients who stopped, or wanted to stop, taking GLP-1s, often because of side effects, and some experienced a deep fear of what’s on the other side of stopping. “There’s unfinished work with their relationship with food that really didn’t get tended to, it was just masked by this medication. Plus, not knowing if they’re going to gain weight, and blaming themselves if they are gaining weight, is a lot to navigate.”

Nicole Patience, MS, RD, CDE, CEDRD, a diabetes and eating disorder specialist who provides weight-inclusive care at Joslin Diabetes Center and CNC360, both in the Boston area, says someone who uses food to manage emotions then loses their appetite on a GLP-1 might not have other tools to rely on. “Because eating disorders are oftentimes born out of a desire to feel protected and self-guard against other things, I like to make sure that other maladaptive coping behaviors don’t start to emerge.”

Brooklyn, New York-based Shana Minei Spence, MS, RDN, CDN, author of Live Nourished: Make Peace With Food, Banish Body Shame, and Reclaim Joy, says with many celebrities nonchalantly taking GLP-1s, she’s seen more people wanting to try the medication to get “reunion ready” or “swimsuit ready”—so more for vanity than for a health concern. “I am not shaming anyone for wanting to use medications because I do believe in body autonomy. I just believe that if we didn’t live in a fatphobic and capitalist society, there wouldn’t be a strong desire to try these medications for weight loss.”

Stigma and Shame
Chan says that, as a weight-inclusive dietitian, she’s found the overall influx of GLP-1s both interesting and challenging, in part because of some of the rhetoric around them, including co-opting of antiweight stigma language. For example, taking the message that weight isn’t a personal choice and turning it into, “It’s ‘not your fault’ that you exist in this body and we have this great medication we can offer you to ‘fix’ that.” Culturally, she says it’s disappointing to see a return to “the thinner you are the better” messages. “It really did seem like socially we were having a little bit of backlash to that. Unfortunately, I feel like we’re just backtracking in so many ways because of these drugs.”

Singh says witnessing celebrities, friends, and coworkers “shrinking or getting smaller,” has made some clients start fantasizing about how their life might look different if they were thin, despite doing significant work on body acceptance. “Sometimes as a dietitian that’s great for us to explore, because some of that stuff might have already been going on under the surface.” She says some clients have also felt conflicted about not being aligned with their values around rejecting diet culture, plus shame for being curious about weight loss. “That’s something we’ll talk about a lot, that shame on top of shame, and I try to really emphasize that it’s understandable to want thin privilege.”

Chan says the prevalence of weight stigma and antifat bias in society means some patients and clients in larger bodies may see the medications as an escape from that oppression. “As a provider who has thin privilege and who doesn’t have that lived experience, I can’t tell someone what to do with their body,” she says. “Outside of food, water, and shelter, one of the most important human needs is validation and fitting in, and I think that needs to be a conversation. If someone does go on these medications, as weight-inclusive dietitians, how do we hold that nuance and understand that people get to have a choice and our role is to take the harm reductionist approach and ensure that they are taking care of themselves physically, mentally, and emotionally in the most compassionate way?”

Ensuring Informed Consent
Part of a harm-reduction approach means ensuring that patients and clients are making a fully informed decision about whether to take a weight loss medication. That includes understanding what the drugs do and don’t do, the possible side effects, and what happens if they take the drug and then later go off it.3,4

As part of some research she’s doing, Tewksbury is finding, anecdotally, that some patients do their own research before asking their provider about GLP-1s, while others say their doctor broached the subject. “I have not come across anyone who has been prescribed these medications and did not have a full conversation with their provider nor seek out the information themselves.” While Lloyd says her patients meet with multiple clinicians and are fully informed about these medications, other dietitians find that the responsibility for delivering education falls on them, in large part because of how little time most physicians have with their patients.

“In my experience, our health care system does not allow physicians the time necessary to educate patients appropriately and fully on all aspects of risks, benefits, and strategies for taking a GLP-1,” Harris-Pincus says. “There’s zero time, potentially not full knowledge, and definitely not the skill set when it comes to nutrition.” Nosek says at her hospital, it’s left to the dietitians to explain to patients how the drug works, as well as how much they should be eating and exercising. “The doctors don’t have time to go over all of that. I think that’s a product of the system of health care in general.”

Protein, Muscle, and Malnutrition
While many dietitians have long had to screen for malnutrition in their patient population, the increased use of this new generation of weight loss medications has brought these concerns to the forefront for a broader range of dietitians, including those in private practice. In some cases, patients may have gastrointestinal side effects5 such as nausea and constipation severe enough that adequate food intake is impossible. Other patients might lean into the drug’s appetite-suppressing effects and decide that less food is better. Either way, dietitians are working to prevent the possible health ramifications of inadequate intake of calories, protein, and other nutrients.

Chan says one of her biggest concerns about GLP-1s is related to loss of muscle and bone mass,6,7 especially when they’re recommended to perimenopausal and menopausal women. “We lose about 1% of muscle mass per year, theoretically, after the age of 30. That tissue is important not only from a metabolic rate standpoint but also from the standpoint of your longevity, your quality of life, your overall risk of falling. If we have decreased muscle mass and also have compromised bone density, that becomes a more compounding issue.”

Lloyd says when side effects cause chronic inadequate intake, most patients reach out to her for guidance. “On the rare occasions when someone is under the impression that minimal intake is beneficial, I thoroughly review how all weight loss is not ‘good’ weight loss,” she says, adding that her goal for her patients is not just to lose fat but also to preserve or increase lean muscle mass.

Harris-Pincus says she works with her clients closely to make sure that their dose isn’t so high that they physically can’t eat much. “The goal isn’t just to lower the number on the scale. So that’s where we come in and talk about the importance of nutrients and food. Simply eating less of nutrient-poor foods is going to result in a lower body weight, but it may compromise health.”

Nosek says she has some older patients who want to eat as little as possible while taking a GLP-1, so she explains metabolic adaptation and how much energy it takes to build muscle. “Then I talk about how it doesn’t matter how skinny you are if you can’t get up off the toilet. And what happens if you fall? Will you be able to get up? Will you be able to heal properly? Do you have enough bone density? If you’re only focused on the number on the scale, these are the things that you’re missing.”

Patience has seen drug-seeking behavior in some clients who have lost weight but aren’t eating enough, making continued use of a GLP-1 inappropriate. “The absolute anger, resentment of not having access to that medication that is helping them conform and feel safe in their body is very distressing,” she says. “Our job is to help them make informed choices and try to align with their healthy self and not the eating disorder self, the parts that are maladaptive. We want the medication to be a tool that we use as it’s appropriate to help support health and well-being. But monitoring is the absolute pivotal piece.”8

Chan has counseled clients who are prescribed a GLP-1 to meet a surgical BMI cut-off for gender-affirming care, or for a knee or hip replacement. “It may be a hoop that someone has to jump through in order to get this very necessary treatment.” She counsels these clients on how to structure their lives around possible side effects. “Unfortunately, it does feel a little bit more prescriptive and less of that intuitive, ‘I can eat freely and I can listen to my internal cues,’ because those don’t exist anymore.”

Making Room for Difficult Conversations
Social media isn’t always a place for nuanced conversations on any topic, let alone GLP-1s. Lloyd says that both social and traditional media are barriers to receiving and understanding evidence-based information. “It’s dangerous to glorify or villainize these medications and to generalize them as either ‘good’ or ‘bad,’ just like it’s dangerous for us to classify food, weight, and BMI in this way.”

Nosek agrees that talking about weight loss medications is “a sticky, messy conversation to have, specifically in the online space.” She says, “I think it’s forcing everyone to have that honest conversation about what is it that we really want,” often, she says, it comes down to the desire for more social capital. She says she’s not immune to the pressure to lose weight, and while she feels supported enough emotionally and physically to not “pull the trigger,” not everyone has that support. “It’s really complicated, and it’s not just a ‘yes’ or ‘no.’ It’s so diabolical in the way that it has just turned everything kind of upside down.”

She also says that as a nondiet dietitian, she gets “a lot of hate” from some weight-inclusive dietitians for being very open about the fact she counsels on GLP-1s. “We’re all here, and everything is hard. So, telling someone, ‘This is the right way to live your hard life, and this is the wrong way to live your hard life’ is weird to me,” she says. “I think it’s reductive, which makes me sad because I think we’re better than that.”

Singh thinks dietitians should be open to potential future benefits of GLP-1s, not dismiss them because they’re promoted for weight loss, and to generally create space for nuance. “When I work with a client that’s being denied a very important procedure and they have explored all options, I am absolutely not going to judge them for wanting to go on a GLP-1. I’ve never been denied a lifesaving procedure because of my weight. But if I was, who’s to say I wouldn’t pursue something like that?” As for the long-term impact of these drugs on the dietetics profession, she says that’s hard to predict. “I suspect more people are going to be reaching out in the future when GLP-1s don’t work as expected, which isn’t what I would hope. I’d rather be proven wrong and have people just have positive experiences.”

— Carrie Dennett, MPH, RDN, is the nutrition columnist for The Seattle Times, owner of Nutrition By Carrie, and author of Healthy for Your Life: A Non-Diet Approach to Optimal Well-Being.

 

References
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2. Schulz C, Vezzani C, Kroemer NB. How gut hormones shape reward: a systematic review of the role of ghrelin and GLP-1 in human fMRI. Physiol Behav. 2023;263:114111.

3. Aronne LJ, Sattar N, Horn DB, et al. Continued treatment with tirzepatide for maintenance of weight reduction in adults with obesity: The SURMOUNT-4 randomized clinical trial. JAMA. 2024;331(1):38-48.

4. Wilding JPH, Batterham RL, Davies M, et al. Weight regain and cardiometabolic effects after withdrawal of semaglutide: the STEP 1 trial extension. Diabetes Obes Metab. 2022;24(8):1553-1564.

5. Sodhi M, Rezaeianzadeh R, Kezouh A, Etminan M. Risk of gastrointestinal adverse events associated with glucagon-like peptide-1 receptor agonists for weight loss. JAMA. 2023;330(18):1795-1797.

6. Bikou A, Dermiki-Gkana F, Penteris M, Constantinides TK, Kontogiorgis C. A systematic review of the effect of semaglutide on lean mass: insights from clinical trials. Expert Opin Pharmacother. 2024;25(5):611-619.

7. Herrou J, Mabilleau G, Lecerf JM, Thomas T, Biver E, Paccou J. Narrative review of effects of glucagon-like peptide-1 receptor agonists on bone health in people living with obesity. Calcif Tissue Int. 2024;114(2):86-97.

8. Bartel S, McElroy SL, Levangie D, Keshen A. Use of glucagon-like peptide-1 receptor agonists in eating disorder populations. Int J Eat Disord. 2024;57(2):286-293.