Abstract
“Short-term weight losses between 8% and 21% were commonly reported in well-documented trials coupled with multiple demonstrated clinical benefits.”
We are delighted to publish the article in the American Journal of Lifestyle Medicine by Mozaffarian et al. “Nutritional Priorities to Support GLP-1 Therapy for Obesity: A Joint Advisory from the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society.”
This superb article represents a much needed collaboration between 4 key organizations which are all engaged in issues related to obesity, namely, the American College of Lifestyle Medicine, the American Society for Nutrition, the Obesity Medicine Association, and The Obesity Society. It also represents an authoritative, evidence-based approach to addressing new realities in the area of obesity management since we have witnessed the advent of GLP-1 therapies.
The GLP-1 therapies are the most powerful obesity related pharmaceutical agents for obesity therapy ever developed. As a physician who has also done significant research in the area of obesity, I welcome these meds as an important addition to our toolbox. The article by Mozaffarian et al, represents the definitive statement of how GLP-1 therapies interact with lifestyle modalities to assure not only short-term, but long lasting therapy for obesity.
Obesity represents a worldwide pandemic with multiple, adverse sequalae. In the United States, over 74% of the adult population is either overweight or obese and these numbers have increased dramatically over the past 3 decades. Worldwide 2.1 billion individuals suffer from obesity and these numbers are projected to grow to over 3.1 billion individuals by 2050. Obesity is strongly associated with type 2 diabetes (T2DM) and cardiovascular disease (CVD) making it even more deadly and expensive to treat! Obesity is a chronic disease which requires chronic therapy. It has been difficult to achieve long-term results in any other modality except bariatric surgery.
While obesity is complicated, with multiple underlying etiologies, the final common pathway is an imbalance between energy intake and expenditure. When energy intake exceeds expenditure, increased adiposity results. This can ultimately lead to adult weight gain (very common in the United States) overweight, and obesity. The mainstays of lifestyle therapies for obesity include decreasing energy intake and increasing physical activity along with behavioral counseling.
Multiple pharmaceutical therapies are available to treat obesity but have typically in the past, only resulted in 5%-10% of weight loss. While this is a meaningful amount of weight loss to lower the risk of chronic diseases individuals who are obese often find this disappointing. Of note, all of the medicines available before GLP-1 came with the recommendation to decrease calories and increase physical activity as part of a comprehensive approach to treatment. This recommendation has also been promoted with GLP-1 therapy. Indeed, this recommendation to combine lifestyle therapies with pharmaceutical therapy comes from expert panels o virtually every metabolic disease including T2DM and CVD.
The advent of GLP-1 therapies came to the field of obesity therapy like a thunder bolt! Short-term weight losses between 8% and 21% were commonly reported in well-documented trials coupled with multiple demonstrated clinical benefits. So great was the enthusiasm for these spectacular weight loss results that both the scientific community and the public at large uncritically embraced GLP-1 therapy as almost “miracle” drugs without carefully evaluating some of the potential undesirable mitigating circumstances.
Now with this important paper led by prominent researchers in nutrition, obesity management, and lifestyle medicine, we have the opportunity to place GLP-1 therapy in its rightful place as an important component but not the only solution to an overall approach to obesity therapy. As the authors point out, “numerous practice guidelines recommend multi component evidence-based nutrition and behavioral therapy for patients with obesity.” However, there is a paucity of the use of these recommendations in combination with GLP-1 therapies.
When GLP-1 therapies are used in real world settings, multiple challenges emerge. These include the potential for GI side effects, risk of inadequate nutrient intake from reduced food consumption, and potential adverse consequences for body composition both in muscle and bone which often result from rapid short-term weight loss.
In addition, despite the high adherence rates achieved in clinical research trials of these agents (often exceeding 80% compliance) in real world settings the discontinuance rates of 50% to 67% at 1 year and up to 85% at 2 years have been reported. There are multiple possible reasons for these higher discontinuation rates. Some of these potential reasons include the typically high cost of these medications, GI side effects, or in some instances disappointing weight loss results.
The brilliance of the current paper by Mozaffarian et al, is to combine the phenomenal potential of GLP-1 therapies with the proven efficacy of lifestyle based therapies for obesity management such as healthy nutrition, regular physical activity and behavioral counseling. The goal of this current paper and, indeed the goal that we should all try to achieve in obesity management, is to combine the proven short-term benefits of GLP-1 therapy with strategies to enhance long-term maintenance of healthy weight loss while minimizing adverse effects and symptoms.
The practical, evidence-based approach adopted by this paper, namely, combining a pharmaceutical breakthrough with long-term proven lifestyle strategies, makes this a seminal paper in the field of obesity management. It further opens the pathway to similar approaches in other chronic disease management categories. The combined expertise of the American Society for Nutrition, American College of Lifestyle Medicine, and the 2 leading professional organizations in obesity management assures wide spread adoption in the in the scientific and medical communities. Moreover, this thorough and extensively referenced document provides scientific evidence at the highest level.
There is no question that weight gain and obesity extract an enormous toll both for individual patients, the health of the world, and its economy. The combined expertise of ACLM, ASN, the Obesity Medicine Association and The Obesity Society to place GLP-1 therapy on firm footing along with the extremely important lifestyle factors offers an important opening to finally make substantial progress to combat this worldwide, devastating pandemic.