Nutritional Counseling Remains Key in Obesity Treatment
Studies on glucagon-like peptide 1 receptor agonists (GLP-1 RAs), such as semaglutide, have demonstrated significant weight loss of 14% over 68 weeks, tirzepatide 18% over 72 weeks, and retatrutide even 22% within 48 weeks.
'These are numbers we cannot achieve with nutritional counseling alone — perhaps in individual cases, but generally, it is utopian,' emphasized Elisabeth Schieffer, MD, from the Department of Cardiology, Angiology, and Internal Intensive Care Medicine at the University Hospital of Giessen and Marburg in Marburg, Germany.
Enduring Relevance
Despite these impressive results, Schieffer views nutritional counseling as an essential component of obesity treatment. She is supported by the authors of the 2024 updated S3 guideline on the prevention and treatment of obesity, which also emphasizes that nutrition, exercise, and behavioral therapy are the cornerstones of every weight management program. According to the guidelines, pharmacologic treatments should only be used in conjunction with multimodal basic therapy.
The rationale is that basic interventions were always carried out in the approval studies for the new drugs — albeit often only as general recommendations for healthy eating and exercise, not as structured programs, as Schieffer noted.
Nevertheless, 'the 2024 guideline clearly mandates us to integrate nutrition with exercise and behavioral therapy in obesity treatment,' stated Schieffer.
Risk Mitigation
An often-overlooked benefit of nutritional counseling in daily practice is the possibility of minimizing the risks associated with weight loss.
'We are dealing with an intervention that can also cause complications,' Schieffer said.
Common issues associated with weight loss include hypoglycemia, weakness, dizziness, difficulty in concentrating, and constipation. Moreover, more severe complications can occur, which can be detected or avoided early through accompanying nutritional counseling, such as electrolyte disturbances (with the risk for cardiac arrhythmias), gout attacks, and gall and kidney stones.
Often, subtle nuances in patients' dietary habits can cause significant problems. Schieffer cited an instance in which patients attempting to increase their fluid intake through rhubarb juice spritzer can significantly increase the risk for kidney stones due to the oxalic acid consumed. 'These are details that can be very relevant in individual cases — which we often do not recognize in time without accompanying nutritional counseling,' she emphasized.
Focused Attention
Schieffer also highlighted specific at-risk groups for whom accompanying nutritional counseling is particularly important.
These include:
Patients with hypertension: Weight loss may require adjustment of antihypertensive medication. Patients need to be prepared to avoid hypotension with a risk of falling, for example, by regularly monitoring their blood pressure at home.
Patients with diabetes mellitus: Close monitoring is essential during GLP-1 receptor agonist therapy to minimize the risk for hypoglycemia.
Patients with heart failure: Although weight loss is generally not recommended for older individuals, younger patients with severely impaired cardiac function (eg, due to dilated cardiomyopathy) may benefit from medication-induced weight loss when combined with nutritional counseling.
Patients with depression: Particular care should be taken to ensure a high-quality diet and preserve muscle mass during weight loss.
Although the new medications predominantly reduce fat mass, some muscle mass is always lost. A 2024 review article revealed that the ratio of fat to muscle mass loss under GLP-1 RA is favorable; however, maintaining muscle mass remains an important goal.
Protein Considerations
'Often, the question then arises whether a higher protein intake would be sensible,' said Schieffer. However, evidence shows that macronutrient composition during weight loss plays a minor role. The standard recommendation of approximately 0.8 g protein per kg body weight still applies. An increase to 1.0-1.2 g/kg may bring minimal benefits but only in combination with strength training.
Schieffer recommended making the prescription of nutritional counseling as straightforward as possible for practical implementation. Medical necessity can be certified informally, for example, on a 'white sheet.' Alternatively, the German Society for Nutrition provides a similar form.
With the certificate, patients can either contact their health insurance provider directly or obtain a cost estimate from a nutrition counselor. Patients who wish to learn more can be referred to the patient guidelines on the diagnosis and treatment of obesity, according to Schieffer.
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