A doctor conversation regarding GLP-1 coaching.
Many of the posts here can also be found on my Substack page. Sometimes I have a “conversation” with another Substack writer about a topic, and recently I had such a conversation with another physician. I will only identify her as Dr. B here. She is a primary care physician in the US and has decades of experience treating a variety of patients, even those seeking GLP-1 medications for weight loss. I recently wrote a response to her post regarding a recent patient she treated with a GLP-1 for weight loss, and for other medical benefits, and gave some coaching that could be considered for patients either wanting to lose weight or become healthier through lifestyle.
Many of us should know some about the GLP-1 medications. These medication include Ozempic, Victoza, Trulicity, and a few others. Some GLP-1 medications are in a combined for with another medication, and these include Mounjaro for one. I am not going to go into the pharmacology or science behind these as this information can be found elsewhere on reputable sites for patients like Cleveland Clinic, Harvard Health, and NIH Statpearls. Many other sources exist, I would heavily endorse those that come from established universities and institutions of research and education. I would not endorse knowledge gained from sites or organizations selling the products or who make claims that sound fantastic (too good to be true) or come without citations.
Anyone curious about using these medications will need to work with their provider who knows them well and help them make an informed choice. This is because everyone’s health history, lifestyle, need or want for these medications, and complicating factors will be different. Only a provider who knows you well can help you make a decision like this one.
This is why I have transferred the conversation I had on this subject form Substack to here. I have changed some of the names and details to respect the anonymity of those involved. For reference, I am Dr. M, the other physician caring for the patient is Dr. B in Italics, and the patient is Lisa. LM stands for Lifestyle Medicine.
Here are the biggest takeaways from what I have written below:
1. Ask permission to have the conversation about eating pattern (diet) and exercise, or other lifestyle habits. This can also be used by patients when they want to have a particular conversation with a provider.
2. What are the patient’s thoughts on how they think they can make a change?
3. Micro-coaching. Triaging of care and responses.
4. Don’t forget about the partners who can either help or hinder any health goal of the patient.
5. Where does the patient want to be in 1 year? 5 years? Or after they stop of the GLP-1?
Dr. B: She is just a hair over five feet tall and weighs around 250 pounds. That’s a BMI of 48. Above 30 is classified as obese. Ideally, according to the charts, she’d weigh less than half of what she does now. She is 36 years old, married, has two children, and works in an office. She has previously been diagnosed and treated for sleep apnea. I see her quarterly for high blood pressure. Obesity is a major contributing factor for both of these conditions. The bodies of young people can tolerate a lot of abuse, but by middle age, obesity starts wearing them down.
Dr. M: I teach that to start any new conversation about lifestyle habits should either be the prerogative of the patient (they come in wanting to talk about it), or (more commonly) the provider has asked them if it is okay to discuss X or Y? If the patient can’t come up with a priority they want to talk about, then the provider offers their priority. This is one of the first steps towards getting patient buy-in and engaged so they can help make up their own goals. When they make their own goals they are more likely to accomplish them.
Dr. M: Also, the comment about “The bodies of young people can tolerate a lot of abuse, but by middle age, obesity starts wearing them down” is very true. While younger (teens-20s-30s and to some extent 40s) will have loads of energy, perfect appearing labs and vitals, be active, and have a lot of reserve or ability to recover from illness and injury pretty well, lifestyle choices that lead to obesity at a young age will be carried on by most throughout life and the consequences will be seen eventually. It is harder to change lifestyle habits later in life than it is at a younger age.
Dr. B: I inquire about exercise and diet. Lisa tells me that she exercises as much as she can between her job, driving her kids around, attending their soccer games, school plays, and parent-teacher conferences. In other words, not much.
Dr. M: Knowing more about her job and when it really entails may help point out that she could consider using any time and/or facilities available to get more physical activity in, even if it is just 10-15 minutes on a break. “Is there any time during your work day to go for a walk? Studies show that the greatest benefits of moving more come when someone adds even just 10 minutes here and there.” If she says she does exercise, “How many times a week do you engage in moderate or vigorous exercise? How many minutes do you exercise each time?” If her baseline is X minutes per week, “Do you feel you can add 5-10 more minutes each time?” Other ways to assess her baseline would be to ask about what she does during the soccer games. Does she see any opportunities to be more active then? She doesn’t go to the gym or have any hobbies involving exercise. “If you were to get pursue more exercise, what would this look like? If a gym is not something she pursues, is it totally out of the question because there is not one close by, open when she needs it to be, too expensive, not her jam? Has she been involved in other forms of enjoyable exercise or physical activity in the past? If she took classes in yoga, palates, aerobics, HIIT, etc. in the past but doesn’t want a gym environment, would she consider an online class she can do anytime? How old are her kids? Would one of them like to join her? How sedentary is her husband? Oftentimes, if LM is treating one person, we must think of the partner and others in the household as well. They can be a great asset or get in the way of progress. Some have included the partner in the conversations even if they are not a patient of the provider.
Dr. B: She says she mostly eats food prepared at home and that she tries to eat healthy. She says she doesn’t eat junk food or drink any soda with sugar. However, she gets her iced coffee with double sugar. ‘t’s my only vice. Most days, I only get one iced coffee, though.’”
Dr. M: Diet is our most modifiable risk factor, but we are all climbing a steep mountain in this society. There are those patients who are successful at changing their eating patterns 180 degrees and sustaining it, but they are uncommon. They also had a lot of help and support, and possibly privilege and personality traits that made it possible. For the other 99%, smaller steps and mindfulness in the behavior change will be a long road but will be sustainable. “When you say ‘prepared food’, what does that usually entail? What does ‘eating healthy’ look like to you?” There are some validated patient questionnaires I include in my class that focus on calculating how “healthy” the patient’s diet is or what it mainly contains. Starting the Conversation is a good one. This can be better and faster than asking a bunch of questions about detailed food diaries or diet recalls. Even asking if she has ever kept a food diary in the past, or if it is something she could consider for the next few weeks could be helpful. The info that comes from knowing more about what they are eating and what they are not can lead to a conversation about adding more things like high fiber foods, plant based or lean proteins, and replacing ultra processed or high fat/sugar items. Culinary Medicine likes to take on diet by “crowding out” the unhealthy foods with healthy foods, making micro-choices, and focusing on cooking at home with whole ingredients. If the Iced coffee is her one vice, would she have any thoughts on how to make it at home? Does she recognize how she feels when she craves one? Especially if she feels like she needs a second one that day? Is she just thirsty, or hungry, stressed, tired? Or is she also craving the sweetness of it? Can she replace what she needs with something else first, then wait a bit to see if she really wants the iced coffee with double sugar? If she is just thirsty, can she get some water in then have the coffee if she wants? Also, if she is not making it at home, has she thought of this as an alternative to have more control over what goes in it and make it more special?
Dr. B: “My observation is that both Zepbound and Wegovy have side effects; however, sometimes people will have side effects with one and not the other. The main side effects are nausea and, sometimes, vomiting. Eating many small meals helps with this. For some people, low-fat diets help; for others, low-carb. Some people find taking vitamin B6 twice per day helps. As you get used to being on the medication, the nausea decreases. It’s fairly rare that people stop the medication because of nausea, but I’ve had a few patients who have done so.
“The other side effects people get are constipation and diarrhea. Some people get one or the other. Some get both, alternating. Very few people stop the medication because of this side effect. For those who get this side effect, it tends to lessen over time, but it seldom completely goes away. Sometimes we just have to go up on the dosage more slowly because of the side effects.”
Dr. M: Eating pattern, or diet, choices can also help ease the side effects that many on GLP-1s face. “Paying attention to what you eat on this medication can help a lot at avoiding or lessening the GI side effects. If you are eating less, then what you eat will matter more to how you feel and can help you lose even more weight. What kinds of foods do you see yourself focusing on while you take this medication? Can I suggest some foods you may want to have available to eat to help you if you start to feel nausea or bowel problems?” It probably works better for those who already have some food literacy that tells them which foods are healthy and which are not, but I would imagine that offering the suggestion that when it does come time to eat while taking the medication, the focus should still be on food that will nourish and help the body function. If the ratio of foods eaten were to stay the same, that would be better at least than if the ration switched to the patient on the GLP-1 eating more unhealthy food than healthy. Ideally, the ratio would be more healthy food eaten over unhealthy on the GLP-1, but that may have to do with their food literacy, eating habits prior to taking the GLP-1, and resources.
While we physicians have not been educated on anything but basic nutrition, we should at least have the intelligence to know healthy from unhealthy, and to advocate for eating patterns that most resemble the well-researched and prescribed diets (DASH, Mediterranean, ADA, AHA), all of which are plant forward. We should know that beans are a great source of fiber and protein, vegetables do have protein, whole fruit is not bad for diabetics, most ultra-processed foods are unhealthy, and that we do not need to eat our cholesterol. “Chew your calories!”
Dr. B: The weight loss should be slow, roughly five pounds per month. Keeping the rate slow is particularly important for patients over fifty. If weight is lost too quickly, the patient will lose muscle mass. With older patients, this will make them become less mobile and more likely to fall. For all patients, rapid weight loss can produce undesirable side effects such as hair loss, stretch marks, and loose, sagging skin. Eating extra protein helps mitigate the muscle loss, but does not prevent it.
Dr. M: While building and maintaining muscle takes both protein intake AND exercise, asking more about food choices while on the medication is helpful. “Where do you get most of your protein everyday? While it would still be important for you to eat a balanced diet while on this medication, not too much protein but not too little either, maintaining muscle strength will be key to helping you maintain energy and help you keep the weight off.” Lisa is still pretty young and in the years where she will need to at the very least hang on to the muscle she has or even work on gaining more. However, she could still be encouraged as her weight decreases to exercise more as patients are often more comfortable with exercise after losing a bit of weight or just find it easier after some pounds are lost.
Dr. B: Most of my patients want to lose weight more rapidly than is good for them. Almost none of them are willing to make the large increase in their exercise levels such that they could preserve or build muscle mass at such rates of weight loss.
Dr. M: Planning for the future from the beginning builds report and trust as well. “Where do you see yourself after one year on this medication? Is there a goal weight at which we would consider stopping the medication? Can we look forwards to discussing the plan for eventually stopping the medication and what your eating and exercise may be for that time?”
I wonder a lot about the next few years of these medications and what will happen when people stop them. They are not built to be a sustainable way to get healthy. It does seem like those who lose weight on GLP-1s and keep it off after stopping them (and keep the other health benefits) are those who have been educated on the risk of weight re-gain and are proactive, have resources, and a mental dedication to keeping the weight off. In other words, they have successfully pivoted into another weight loss practice that is working for them. I am waiting to see if LM takes this subject.
Dr. B: “The medication works so well. I used to think about what I was going to eat at my next meal all the time. Now, I eat when I’m hungry and not other times. Sometimes I have to remind myself to eat. It’s so weird and so easy. It used to be that if I tried to lose weight I wouldn’t be able to think about anything else except what I was eating. Or, I should say, what I wasn’t eating and wanted to eat…..[I used to feel]bad because I had no self-control. Now, I just eat food, and it’s not a big deal. I used to feel like I was a bad person because I was always hungry, like everyone thought I was lazy, and didn’t want me around. I wish it could have been so easy to lose weight before.”
Dr. M: I have heard variations of this from others, a sense that the “noise” in the head was now gone on the medication, food meant something different, and/or they don’t feel guilt through feeling hungery. This is a topic I would like to learn more about, and it may be something we will see researched on more in the future - the psychology of GLP-1s. “It seems like you feel more a sense of control and that maybe the stress of seeing weight loss as have ‘no self-control’ or feeling ‘lazy’ or like a ‘bad person’ is gone now. That is great! Weight loss should not be about feeling hungry or bad. Weight loss should be about being empowered and feeling good in your own skin, having energy and feeling confident. Now that you have lost some weight, how do you feel about taking some more steps towards maintaining the weight loss and feeling great?”
For providers, a kind of triage approach can be done with LM coaching. Knowing the time constraints and that fact that micro-coaching during visits usually isn’t reimbursed. Patient encounters usually have to be whittled down to core questions, routine algorithms, and an ability to mix the history with the exam. Depending on practice structure and location, some good referral sources like dietitians and physical therapist are underutilized.
Lifestyle Medicine can seem like too much too fast and give the impression that a. we have been taught to practice medicine the wrong way for so long, b. trying to incorporate any of its pillars like dietary change or physical activity is futile, and c. it means we will have to work harder for less. I believe that there are elements of truth to these statements but only small ones. As healthcare in general, the practice of medicine more particularly, and society’s behavior when it comes to health habits have changed over the years, evolved, devolved, all this has taken a long time to get to where we are today. It probably will take at least that much time to reverse and see any change in the opposite direction.