When prescribing GLP-1 RA, don’t forget the RDN referral
The tide has been turning in nutrition counseling for weight management. With the increase in prescriptions for weight loss medications, dietitians are having different conversations with patients. While balanced nutrition is still the ultimate goal, the challenges to achieving this balance are changing. Patients are reporting differences in how they think and feel about eating--but the changes are not without concern.
There has been much ado about the GLP-1 receptor agonists such as Ozempic, Wegovy, Mounjaro, Zepbound, and their oral counterpart Rybelsus. In the past, those with higher weights were threatened with the risk of diabetes and wanted to avoid medication injections. Now, people are requesting the injectable weight loss meds, which were originally designed to treat type 2 diabetes. With or without diabetes, the demand is high.
Indeed, it is hard to argue their effectiveness. Celebrities are basking in the limelight for their new physiques. People with higher weights are seeing relatively fast results. Doctors are seeing improvements to blood pressure, blood glucose, lipids, and other measures of health. Commercial weight loss programs are adjusting their plans so they, too, can cash in on the hype.
Seeing Results
As a dietitian, I am pleased for my patients who are benefiting from these medications. Not just because of the physical and metabolic changes that people are seeing, but also for the mental and emotional benefits that they report. People say that they no longer think about food as much as they did before. With less cravings, some demonstrate an improved relationship with food. Without the food noise, there is less anxiety and guilt around eating.
Some Concerns
As with any medication, however, there are some side effects to consider. The word is out on the gastrointestinal symptoms, including bloating or nausea. There may also be an increased risk for gallstones. The medication is contraindicated for those with certain GI or pancreatic conditions.
For some, the side effects are intolerable and cause them to quit the medication, which can result in weight regain. A recent study suggests that users must remain on the medication indefinitely to maintain their weight loss (Aronne 2024). These findings can be a hard pill to swallow for those who hope the medication is a short-term treatment to “jump start” their progress. Also, while the general safety of the medications has been vetted, the future effects of long-term use is still to be determined.
The potential to regain weight after discontinuing a weight loss treatment is not a new story. Previous medications, diets, meal replacement products, and other weight loss programs have repeatedly demonstrated the same fate: Effective until discontinued. Even bariatric surgery has no guarantees.
A Deeper Look
With each of these strategies, registered dietitian nutritionists have been uniquely positioned to observe the complex interplay of the physiological, emotional, social, and situational factors that can support–or undermine–these treatments. Trained to look beyond lab values, RDNs assess health behaviors for long-term quality of life. Therefore, RDNs are an integral–yet too often dismissed–part of the treatment. They are generally the only members of the healthcare team who are afforded the training and the time to assess nutrient intake and health behavior, then provide personalized nutrition education and lifestyle counseling. A comprehensive nutrition assessment may reveal red flags for long-term concerns.
With more people using GLP-1 RAs, dietitians are observing a concerning trend: inadequate intake. Before, patients complained of sugar cravings and eating patterns that included periods of overeating or mindless eating. Now, those using the medications find themselves rarely hungry. Sometimes, they say they have to force themselves to eat. Some even find that their sensation of thirst is stunted and they do not hydrate properly, which can increase the risk for gallstones, constipation, or other complications related to inadequate hydration.
When a dietitian hears that their patient eats only one meal a day, they are less likely to celebrate a reduction in calorie consumption. Instead, they know they have to dig deeper to make sure the patient is not at risk for nutrient deficiency, muscle loss, or malnutrition. What good is weight loss if your patient feel fatigued or weak? Sure, blood sugar and lipids might be in range, but if too tired to be active, future health may still suffer (WHO).
Beware the Bias
Unfortunately, weight bias–both implicit and explicit–is well documented among health
professionals (FitzGerald et al. 2017; Wijayatunga NN et al. 2021). These biases can allow situations of malnutrition or eating disorders to slip through the cracks for patients with higher weights. Providers might turn a blind eye to nutrition if body weight and metabolic conditions improve. After all, their patients are seeing results. However, nutritional deficiencies have been found to be prevalent in people with higher weight (Kaidar-Person 2008). Older adults are also at risk of malnutrition and sarcopenia, a condition of muscle wasting and fragility.
Some studies have looked at the effects of GLP-1 RAs on body composition and strength, reporting no significant decline (Volpe 2022, Ozeki 2022). However, these investigations are still too few and too short-term to make long term conclusions. Furthermore, these investigations have been performed in Europe and Japan, thus do not reflect how the typical American diet and lifestyle might affect the outcomes. Often characterized as higher in ultraprocessed foods and lower in physical activity compared to other countries, the American lifestyle might affect outcomes differently.
It Will Always Come Back to Nutrition
Hence the importance of proper nutrition and lifestyle guidance. Protein supplements and green powders are not enough. A multivitamin is not enough. To date, swapping food for manufactured formulations has not proven superior to well-balanced diets for long-term health. Furthermore, diet and lifestyle have been shown to improve health-related indicators regardless of body weight (Matheson EM et al. 2012).
In addition to providing the basic building blocks and fuel sources for biological function, the therapeutic effects of food should not be forgotten. Phytochemicals, antioxidants, fiber, and healthy fats have all shown to be protective against disease. In contrast, undernourishment hardly has a tick in its favor. In addition to feeding the person, nourishing the gut microbiota also requires a diet high in fiber and plant foods. Certain gut microbes are credited with a host of benefits including metabolic and mental health. From the smallest organisms to the whole person, the role of food will always be the mainstay of vitality--one no medication can replace. Therefore, the benefits of weight loss without regard to proper nutrition may prove detrimental in the long run.
An Underutilized and Undervalued Resource
Through careful assessment and nutrition-focused physical examination, dietitians screen for diet-related concerns, then assist patients with practical solutions. They incorporate the patient’s lifestyle, preferences, medical conditions, socioeconomic and/or psychosocial barriers into a collaborative approach to problem solving. In regard to GLP-1RAs, dietitians can help patients learn how to plan and prepare their foods in ways that mitigate the side effects. Thus, not only can proper nutrition guidance help the patient maintain their overall health, but may also keep them from quitting the medication due to side effects.
Unfortunately, access to RDNs is limited. Some physicians do not regularly refer their patients to dietitians, and insurance does not always cover medical nutrition therapy. Thus, for those using GLP-1 RAs, they suffer through the medication’s side effects, and are not screened for proper nutrition. Some patients--and some healthcare professionals--have a misconception that less is more when it comes to food. Registered dietitians, on the other hand, help people understand the therapeutic and protective benefits of food, and how to reap those benefits.
While RDNs are equally pleased to see their patients reaching their personal weight goals, they also recognize that nutrition will still be the safety net that can help manage side effects and maintain overall health. For those who decide to quit the medication, dietitians will be key in helping people continue to develop their health behaviors.
Time and again, history has shown that there is no one magical potion or diet for weight loss and health. While the pathophysiology of obesity may be combated with pharmaceutical intervention, to discredit or ignore the impact of lifestyle and nutrition would be misguided. To truly optimize care, prescribers should include a referral to a registered dietitian with any treatment for weight loss.
For the dietitian, nutrition counseling goes beyond meal plans and calorie counts. Exploring a patient’s barriers, emotions, and motivations requires an intimate exchange of information. Patient education should include evidence-based strategies for lifestyle change. Preventing relapse will require relationship-building for ongoing support. These topics are discussed in detail in the upcoming book, Think Like A Dietitian: A Nutrition Counseling Starter Kit, due out in March 2024. Topics include:
Structuring a nutrition assessment, including breaking the ice.
The dietitian-patient relationship and building trust.
Patients’ FAQs and other things you'll hear in nutrition counseling.
And more!
The book also comes with downloadable patient education materials, including colorful, graphical slide presentations, handouts, and counseling worksheets.
For updates on the book’s release, subscribe below. To start adding to your education toolkit today, go to www.platemethodpics.com.
References
Aronne LJ, Sattar N, Horn DB, Bays HE, Wharton S, Lin WY, Ahmad NN, Zhang S, Liao R, Bunck MC, Jouravskaya I, Murphy MA; SURMOUNT-4 Investigators. Continued Treatment With Tirzepatide for Maintenance of Weight Reduction in Adults With Obesity: The SURMOUNT-4 Randomized Clinical Trial. JAMA. 2024 Jan 2;331(1):38-48. doi: 10.1001/jama.2023.24945. PMID: 38078870; PMCID: PMC10714284.
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017 Mar 1;18(1):19. doi: 10.1186/s12910-017-0179-8. PMID: 28249596; PMCID: PMC5333436.
Kaidar-Person O, Person B, Szomstein S, Rosenthal RJ. Nutritional deficiencies in morbidly obese patients: a new form of malnutrition? Part A: vitamins. Obes Surg. 2008 Jul;18(7):870-6. doi: 10.1007/s11695-007-9349-y. Epub 2008 Mar 4. PMID: 18465178.
Matheson EM, King DE, Everett CJ. Healthy lifestyle habits and mortality in overweight and obese individuals. J Am Board Fam Med. 2012 Jan-Feb;25(1):9-15. doi: 10.3122/jabfm.2012.01.110164. PMID: 22218619.
Ozeki Y, Masaki T, Kamata A, Miyamoto S, Yoshida Y, Okamoto M, et al. The effectiveness of GLP-1 receptor agonist semaglutide on body composition in elderly obese diabetic patients: A pilot study. Medicines (Basel) (2022) 9(9):47. doi: 10.3390/medicines9090047
Volpe S, Lisco G, Racaniello D, Fanelli M, Colaianni V, Vozza A, Triggiani V, Sabbà C, Tortorella C, De Pergola G, Piazzolla G. Once-Weekly Semaglutide Induces an Early Improvement in Body Composition in Patients with Type 2 Diabetes: A 26-Week Prospective Real-Life Study. Nutrients. 2022 Jun 10;14(12):2414. doi: 10.3390/nu14122414. PMID: 35745144; PMCID: PMC9227575.
Wijayatunga NN, Bailey D, Klobodu SS, Dawson JA, Knight K, Dhurandhar EJ. A short, attribution theory-based video intervention does not reduce weight bias in a nationally representative sample of registered dietitians: a randomized trial. Int J Obes (Lond). 2021 Apr;45(4):787-794. doi: 10.1038/s41366-021-00740-6. Epub 2021 Jan 27. PMID: 33504932
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