How to Guide Your Patients With Obesity to Optimize Health

In 2023, Tamara Hall reached a crossroads. At 5’11 and 336 pounds, she had undone all the progress she made 10 years earlier when she lost about 100 pounds through the WeightWatchers program. She had successfully maintained her weight loss for a few years, but then life got in the way. A second child, followed by her divorce, led to some of the hardest times in her life.

“It was just a mess,” she said. “Financial things, you know what I mean.”

The healthy habits Hall had worked so hard to put in place eventually dissolved. Instead of healthy meals, she ate at Wendy’s and Taco Bell. She stopped working out and eventually she could not keep up with her 3-year-old daughter. The last straw was when she was diagnosed with type 2 diabetes. “That was enough for me to say it’s time for a change.”

Hall — a 45-year-old, Las Vegas-based analyst at T-Mobile — returned to WeightWatchers. Only this time it offered a new option — the chance to meet with a clinician, and if you qualified, to start on a glucagon-like peptide 1 receptor agonist (GLP-1 RA) medication, a class of medications that can help manage obesity and diabetes. Hall chose Mounjaro (tirzepatide).

Her journey to 150 pounds of weight loss was hard, she said, but doable. If she can do this at the age of 45 years with three kids, anyone can, she said. “Don’t wait for the right time…Just press play. Just go.”

How are healthcare practitioners helping their patients who are obese in their healthy living journeys? Here’s what they said.

Taking A Personalized Approach 

“I think the most important piece is that you really want to provide personalized care in order to optimize somebody’s weight/health journey,” said Michelle Cardel, PhD, chief nutrition officer at WeightWatchers and a registered dietitian.

The behavioral piece, including diet and exercise, is the cornerstone, Cardel said. It can be used alone or in combination with pharmacological treatment or bariatric surgery.

Mihir Patel, MD, also tries to personalize programs for his patients who mostly have class 2 and class 3 obesity (with a body mass index of at least 35). Patel, an obesity medicine specialist at the University of Maryland School of Medicine, Baltimore, talks to patients about their weight history, whether obesity was present since childhood or whether there were particular points when their weight increased significantly.

He goes through everything they eat throughout the course of a day and then may recommend a specific diet, he said, such as the mediterranean diet, a more plant-based diet, the ketogenic diet (very low carbohydrates) or the Dietary Approaches to Stop Hypertension diet, an evidenced-based approach.

Patel may also help patients structure their day to “time their meals or use different foods to try to help them with weight loss, to help them balance hunger and satiation,” he said.

For example, one of his patients wasn’t eating much before exercising in the evening and was gaining weight, so Patel encouraged him to eat a more substantial breakfast and have more protein for lunch before going into his evening work-out routine.

Patel also generally offers GLP-1 RA medications to patients who qualify on their first visit.

Robert Kushner, MD, a professor in the Departments of Medicine and Medical Education at Northwestern University Feinberg School of Medicine in Chicago tries to find out where patients with obesity are at with nutrition and then encourages them to get healthy in a stepwise or progressive fashion. If a patient generally has a bagel with cream cheese and coffee with cream from Dunkin’ Donuts for breakfast, he suggests they consider substituting foods that are higher in protein and lower in sugar such as yogurt with fruit, a protein bar, or an English muffin with peanut butter.

Don’t expect to accomplish everything in one visit either, he said. If the patient cannot return for another visit in a month, consider reaching out to them to check in on their progress using a telehealth method, he said. Doctors can also consider referring patients to a registered dietitian for more in-depth guidance. There are also apps, such as MyFitnessPal, where patients can track their daily food consumption which helps build awareness of the calories you’re taking in, he said.

WeightWatchers now offers a specialized lifestyle program for members taking a GLP-1 RA medicine. Pairing the GLP-1 RA, if it is advised, with a behavioral program focusing on diet and exercise is key to success and that’s why the US Food and Drug Administration recommends a lifestyle modification program to accompany these medications, Cardel said. 

This tailored program also monitors a person’s protein and vegetable intake and water consumption, Hall said.

“Because all of that is important, that you’re getting like all of the nutrients and protein,” she said.

It’s also important to make sure you’re not losing muscle, she added. Because you’re on a GLP-1 RA, the WeightWatchers points system doesn’t really matter because the medication is going to suppress one’s appetite and make it harder to digest certain foods. Hall was also able to see a registered dietitian monthly.

The focus of the lifestyle program for those taking a GLP-1 RA is on nutritional adequacy, making sure patients eat enough protein, stay hydrated and engage in resistance training at least two to three times a week, Cardel said. The dietary piece can also help with unwanted side effects of the medication including nausea, vomiting, and constipation.

For those who don’t take a GLP-1, the calorie deficit must be a part of the equation, Cardel said. Most people who are overweight should focus on losing 1-2 pounds per week and that usually happens by cutting 500-750 calories per day, Cardel said. Food tracking is one of the most “evidence-based” ways to lose weight.

At WeightWatchers, participants have a daily points budget which helps facilitate this deficit, but “we also have a weekly point budget and that provides the built-in flexibility” she said. If you want to go out for dinner with friends and have wine and dessert, for example, you can use your weekly points budget.

The hope is to “behaviorally nudge people” to healthier options while still being in a calorie deficit, Cardel said.

Points are personalized based on a person’s height, weight, age, and sex. Points also go down for foods higher in protein and fiber and up for foods higher in added sugar and saturated fats. There are also many zero-point foods — such as seafood, lentils, fruits, or oats.

“There are always go-to healthy food options that you can reach for,” Cardel said. Focus on getting 30 g of protein at every meal and 30 g of fiber per day, she said.

The goal is for people to stay on the program long-term, Cardel said.

‘Weaving in Fitness’

People also should engage in moderate to vigorous physical activity for at least 30 minutes a day or at least 150 minutes per week, Cardel said, and incorporate strength training. However, when Patel sees obese patients, he tries not to “harp on exercise” during the first visit.

“…Some of the data shows that if you gradually weave in exercise kind of over their weight loss journey and kind of build toward something, that people end up doing better, they kind of stick with the exercise and end up keeping more weight off in the long run,” Patel said.

He refers to this randomized controlled clinical trial (published in Obesity in 2019) which concluded that the “timing of exercise initiation can be personalized based on patient preference.” 

If people want to exercise hard, he supports that, but usually for most people he suggests taking small steps like parking further away from your destination, wearing ankle weights while doing laundry or cooking at home. Then he recommends gradually weaving in more exercise over time. People are relieved when he tells them they don’t have to go all the way into exercise. Finding the time to exercise can be a challenge and it can take time to figure that out.

Also, “a lot of people just have physical limitations. And as we kind of lose weight with some of the other methods they can kind of build in some more exercises in there, you know their back feels better, their knees feel better.” 

When Kushner sees patients, he finds out how much they are already exercising and builds from there. If they’re already walking, then perhaps add 10 minutes, he suggests. Also set realistic and attainable goals, he said. Don’t just say walk more, say walk 3 days a week at a set pace. That’s doable.

There’s another reason Patel doesn’t fixate on exercise. “As a purely weight loss tool, it’s probably not the best tool,” he said, 

Research shows that for every 10 pounds you lose, about eight are the result of the changes in diet and about two of them are likely reflective of changes made in physical activity, Cardel said.

But exercise is still important during the weight loss piece because of all the benefits for overall health and well-being including mental health and heart health, Cardel said.

It also helps with fitness and strength, Kushner added.

Exercise does work well for maintaining weight loss, but it takes working out for about 1 hour a day to keep the weight off, he said.

It’s key to find a type of exercise you enjoy, and you’ll be more likely to stick with it, Cardel said. While many people think you have to be doing a really intense workout, the reality is you just need to move your body. “It can be as simple as taking a walk,” she said.

Real World Results

When Hall first started on Mounjaro, she didn’t do any physical activity and focused only on acclimating herself to the medication. She felt nauseous and it was hard to move at first, but over time she began to build in more physical activity. Ten years earlier when Hall lost weight, she lived in the gym 6 days a week, but this time she wanted to do it in a more sustainable way.

She started by walking about 1 mile per day during her breaks at work. “Fifteen minutes of movement a day is attainable,” she said.

She also began lifting weights at home for at least 15 minutes per day. The strength training was particularly important to maintain muscle mass as Mounjaro caused rapid weight loss in the beginning for Hall.

Today, she weighs 187 pounds (122 pounds is muscle). She is proud of herself. She can run and keep up with her kids.

“Looking good is one thing, but feeling good, being healthy, that’s something totally different. That’s where it’s at,” she said.