A Guide for Discussing GLP-1s as Obesity Treatments

The arrival of drugs that mimic the gut hormone glucagon-like peptide 1 (GLP-1) has revolutionized the treatment of overweight and obesity, offering a biologic intervention that targets the root neurohormonal and genetic causes of these chronic conditions. However, the journey to successful treatment can be fraught with challenges, including patient hesitancies carried over from earlier failed treatments, unrealistic weight loss expectations, and managing side effects that contribute to early discontinuation.

For clinicians, addressing these potential obstacles with patients during visits that, on average, may last just 20 minutes, is no small task.

“Our traditional medical system is just not set up for one person to be able to give all this information at one visit,” said Alexandra Sowa, MD, a clinical instructor at New York University Grossman School of Medicine, New York City. In fact, this conundrum inspired her new book, The Ozempic Revolution: How GLP-1 Drugs Can Help You Reverse Obesity, End Yo-Yo Dieting, and Protect Yourself From Disease, which Sowa bills as “the first comprehensive companion guide to succeeding on GLP-1 medications.”

This article provides actionable strategies and resources, provided by Sowa and other experts in the field, to help clinicians optimize the patient journey with GLP-1 therapies and achieve meaningful outcomes.

Overcoming Hesitancy

GLP-1 receptor agonists are approved by the US Food and Drug Administration for obesity or overweight with at least one weight-related condition (eg, type 2 diabetes or hypertension) including semaglutide and liraglutide, as well as tirzepatide, a dual agonist that activates both the GLP-1 receptor and the glucose-dependent insulinotropic polypeptide (GIP) receptor.

Since the start of the current decade, prescriptions of GLP-1 receptor agonists for obesity without diabetes have risen, whereas those for type 2 diabetes have fallen. Yet, this trend does not mean that all candidates for GLP-1s with overweight/obesity are eager to embrace their use.

Recommending GLP-1s for a patient may begin with addressing their deeply valid and entrenched hesitancies.

“Unfortunately, there’s a history of weight loss medications that have been catastrophes,” said Sowa, citing the example of fenfluramine/phentermine, which was withdrawn from the market in 1997 after the use of fenfluramine was linked to heart valve damage.

Many patients also feel they’ve been failed by a healthcare system that has historically stigmatized weight loss rather than approach it as a chronic disease.

“In their lifetime, they’re always told weight loss was up to the individual, and it was more about willpower than biology, when we now know the reverse to be true,” Sowa said.

In The Ozempic Revolution, Sowa provides a crash course in “Obesity Medicine 101,” debunking the “eat less, move more” rhetoric that dominated weight loss advice for decades. She details how scientific advances have revealed neurohormonal dysregulation and genetics as the two main routes for causing and sustaining overweight/obesity. Her book simplifies the complex feedback mechanisms that occur throughout the body to contribute to these conditions, including the prominent role of GLP-1, GIP, and other weight-involved hormones. Patients learn how GLP-1s and related biologic therapies help regulate blood sugar, reduce hunger, and control brain signals that direct appetite and food intake.

This background is crucial to easing patients into the use of GLP-1s, agreed Mehmet Furkan Burak, MD, an endocrinologist and obesity specialist at Brigham and Women’s Hospital, Boston.

In patient conversations, “I acknowledge what was wrong about obesity treatment before, contrast that with what we’ve learned in terms of biology, and how we now use that to treat the disease, and they (patients) feel much more comfortable,” said Burak. “I tell patients, with this medication, you’re just putting back what is missing, and we’re resetting you to factory settings.”

Patients may also struggle with the idea of self-administering once-weekly injections, said Deena Adimoolam, MD, a specialist in endocrinology, diabetes, and obesity medicine at Summit Health in Clifton, New Jersey.

“For those nervous over injections, I will show them the actual pen, size of the needle, process of giving injections, etc.,” Adimoolam told Medscape Medical News.

Shifting the Focus From Weight Loss

Although GLP-1s’ ability to produce significant weight loss has garnered considerable media attention, Sowa finds that focusing solely on this outcome often misses the mark with patients.

“Hitting a number on a scale, getting to a particular size, and being thin, it loses its luster,” Sowa said.

Instead, she finds that patients respond best to hearing how GLP-1s can offset a variety of long-term health effects. Here, clinicians can draw upon a rich trove of recent data linking their use to a variety of reduced comorbidities.

For example, “evidence shows that GLP-1 receptor agonists can have cardiovascular benefit, improve heart failure, renal disease in people living with diabetes, osteoarthritis, obstructive sleep apnea, and other disease processes that significantly impact patients’ overall health and quality of life,” Priya Jaisinghani, MD, clinical assistant professor in the Department of Medicine at NYU Grossman School of Medicine, told Medscape Medical News. “Discussing these benefits in the context of each patient’s unique health profile can help them better understand how GLP-1 receptor agonists might align with their broader health goals and improve their overall well-being.”

Maria Daniela Hurtado Andrade, MD, PhD, a consultant in the Endocrinology, Diabetes & Metabolism division at Mayo Clinic, Jacksonville, Florida, emphasized setting realistic weight loss expectations.

For instance, she explained that patients looking to lose a third of their body weight might need to adjust their expectations. Instead, she asks about other goals they may have, such as better diabetes control, reduced reliance on medications, or avoiding joint replacement surgery, all of which may be achieved by a relatively smaller percentage weight loss.

“If you change the focus of the conversation from that number on the scale to what is your ultimate goal, then patients can look toward other motivators to get them to their objectives,” Hurtado Andrade told Medscape Medical News.

One helpful motivation, added Adimoolam, is quality-of-life benefits “that make them feel better overall physically and psychologically. For some, it’s a weight to fit into their wedding dress, being able to skydive, being healthy for their kids. Everyone has different goals and objectives for why they want to lose weight.”

Avoiding Treatment Discontinuation

According to a recent analysis of the Blue Cross Blue Shield database, less than half of patients prescribed GLP-1s for weight management took them for the full 12 weeks required to experience clinically meaningful weight loss. A separate analysis found that GLP-1 discontinuation rates were higher among patients taking them for obesity rather than type 2 diabetes.

Jaisinghani pointed to high costs, periodic shortages, and side effects as key contributors to these high discontinuation rates. She recommends clinicians collaborate with patients on strategies to overcome these barriers, such as exploring financial assistance programs or alternative medications.

Burak advised a gradual approach for patients at higher risk for discontinuation.

“We’re not rushing anywhere,” he said. “We need to set the stage from the beginning. If you’re available to them when they experience nausea and other adverse responses, it can dramatically improve discontinuation rates.”

Hurtado Andrade emphasized the importance of educating patients that side effects — most commonly gastrointestinal issues like nausea, diarrhea, and vomiting — tend to subside over time.

“After the third or fourth injection, they are going to improve and perhaps not have any side effects at all,” she said. “Education is a very powerful tool to ensure patients continue their medications long-term.”

Identifying Triggers for Adverse Reactions

Sowa stressed that GLP-1 medications are not a “magic wand” and must be coupled with changes in eating habits to minimize adverse effects. She recommends patients maintain a food log, which she described as an “old school tool” that she’s nonetheless found to be the most effective for enabling patients to identify triggers behind their adverse reactions.

“If you encourage your patient to write down specifics, it can save a lot of back and forth and enable you to use your expertise to manage problems effectively,” she said.

Adimoolam agreed that having patients “listen to their body” provides valuable insights. For some, fried foods may worsen gastrointestinal side effects; for others, it might be acidic or spicy foods.

Jaisinghani suggested focusing on nutrient-dense foods while avoiding those that may aggravate discomfort.

Sowa noted that, because the hormonal pathways that regulate hunger also regulate thirst, patients taking GLP-1s can inadvertently reduce their consumption of water, in turn contributing to common gastrointestinal symptoms. She recommends having patients commit to consuming 64 oz of water daily.

Timing is another critical factor, said Hurtado Andrade.

“If they’re eating right before going to bed, nausea, bloating, and fullness sensation can be more pronounced.”

Burak advised that clinicians must consider the individual factors behind patients’ food choices, identifying what’s problematic but also leaving room to be flexible, where possible.

“I ask them about their plans, their values, their cultural cuisine, and the things that they really enjoy eating,” he said. “We don’t want to torture people. We just want to achieve a sustainable weight loss and establish new habits.”

Guidance for Primary Care Physicians

Recent evidence suggests that most GLP-1 prescriptions for weight loss come from primary care physicians, rather than specialists. Sowa said that although these medications have been available for some time, the relative boom in prescriptions undoubtedly presents challenges for primary care providers unfamiliar with obesity treatment’s latest advances.

“For the general doctor’s office, it can be crushing because it’s changed workflow and patient expectations,” Sowa said.

Although Sowa’s observed a “sea change” in how primary care physicians approach weight loss in recent years, she said they should nonetheless work to ensure they’re up to date on the latest biological information on what causes overweight/obesity and avoid repeating the same diet-and-exercise arguments of years past.

“The fact is, if you were trained any more than about 5 years ago, weight bias permeated your training,” she said.

Hurtado Andrade called for greater involvement from primary care providers in addressing overweight/obesity, which affects approximately 75% of US adults older than 25, reported a recent high-profile study in The Lancet.

“Primary care providers feel comfortable addressing type 2 diabetes and hypertension. Why not obesity?” she asked. “Considering that obesity is a complication for many of the most prevalent chronic diseases, treating it can have a cascade effect of clinical benefits that are truly difficult to even imagine.”

Despite these challenges, Sowa noted that all potential prescribers of GLP-1s should be aware of the pivotal role they can play in not only helping their patients but also setting the stage for improved healthcare patterns that can reverberate for society at large.

“My hope is that these drugs lead to widespread behavioral changes in households,” she said. “If parents cook differently, children eat different foods, and homes shift away from processed foods, the impact on future generations could be profound.”

Adimoolam reported no relevant financial disclosures. Burak is a consultant for Tersus Life Sciences and a speaker for Wave Life Sciences. Hurtado Andrade has received research funding from the National Institutes of Health and Phenomix Sciences. She also has participated in advisory boards for Novo Nordisk. Jaisinghani serves as a consultant and speaker for Eli Lilly and Company and Novo Nordisk. Sowa is the founder ofSoWell, which produces and sells GLP-1 support products.

John Watson is a freelance writer in Philadelphia.