Can Lifestyle Changes and Coaching Support Long-Term GLP-1 Weight Loss Maintenance?
Can Lifestyle Changes and Coaching Support Long-Term GLP-1 Weight Loss Maintenance?
— By Dawn M. Sweet, Ph.D.
Supporting GLP-1 patients with behavior change could improve GLP-1 adherence and long-term weight loss.
Despite several benefits of GLP-1 RA medications for glucose control and weight loss, patients face several challenges with long-term weight loss. GLP-1 adherence can be difficult for many patients for several reasons, e.g., cost and accessibility, side effects, weight-loss plateaus, or psychological factors.
Current pharmacotherapy for obesity often includes GLP-1 medications such as Ozempic, Mounjaro, and Zepbound. These medications are popular not only for their effectiveness in promoting weight loss but also for their ability to help patients manage blood glucose levels, making them a valuable option for those with obesity and type 2 diabetes. Research has clearly shown the importance of pairing a GLP-1 medication with sustainable behavior change, which gives patients the best chance of achieving long-term. Additionally, GLP-1 weight loss maintenance1,2 could also be achieved more efficiently with behavior change.
Integrating a GLP-1 RA medication with behavior-change support could mitigate some of the GLP-1 adherence challenges faced by patients with type 2 diabetes or obesity who are prescribed a pharmacotherapy.
GLP-1 Adherence in Adults with Type 2 Diabetes
A recent retrospective study3 investigated the effect of early response on adherence to GLP-1 RA medications in adults with type 2 diabetes (N = 8,329) over 18 months. Results suggest that patients with an early response to their GLP-1 medication (e.g., HbA1c reduced by > one percent and a > three percent reduction in body weight within the first three to six months of starting the GLP-1 RA medication) were more likely to continue the medication.
In a 2022 study4, GLP-1 RA adherence was investigated in 589 adults with type 2 diabetes. Interestingly, the discontinuation rate of the GLP-1 RA medication among study participants was substantially higher — 45.2 percent at 12 months and 64.7 percent at 24 months — compared to patients enrolled in the SUSTAIN-6 trial (Trial to Evaluate Cardiovascular and Other Long-Term Outcome with Semaglutide Subjects with Type 2 Diabetes), where a 22.6 percent discontinuation rate was recorded at 24 months. The authors note that in real-world contexts, patients appear to discontinue GLP-1 RA medication use sooner than those in clinical trials, thus reducing the effectiveness of GLP-1 RA medications. The authors do note that their sample size was relatively small compared to clinical trials and also note that patients may benefit from additional support to improve long-term GLP-1 adherence in real-world contexts. If patients discontinue their GLP-1 RA medication early, health care providers should follow up with patients to explore the reasons and identify another strategy, such as medically supervised weight loss supplemented by meal replacement products and behavior education.
GLP-1 Agonists and Dietary Behavior Change
GLP-1 RA medications can jumpstart patients’ weight loss; however, for long-term success, it is important to consider the role of sustainable behavior change. Research clearly articulates that there is a high probability of weight regain within two years as well as less desirable changes to body compostion.5 When patients stop taking their GLP-1 RA medication, not only is fat mass added, but the newly gained fat mass replaces muscle mass. Sustainable lifestyle changes to diet and exercise are important considerations.
The benefits of behavioral lifestyle interventions have consistently been supported by research.6 A review of 12 studies (n = 1862; n = 9 RCTs; n= 2 quasi-experimental; n = 1 control study with unknown randomization)2 that investigated the efficacy of lifestyle interventions found that comprehensive and intensive behavioral interventions could yield clinically significant with loss in patients with obesity.
The behavioral interventions ranged from six weeks to one year. Twenty-two behavioral lifestyle interventions had a dietary component: 18 provided daily recommendations for energy and macronutrient consumption; three recommend a very low calorie diet (< 800 kcal/day); 13 recommend a low calorie diet (≥ 800 kcal/day, 500 kcal deficit or 80 percent basal energy); and two recommended macronutrient control (e.g., ≤ 30 g/day). There were 23 physical activity interventions that included specific goals such as the time and number of steps per day (e.g., 30-60 minutes of moderate exercise five days/week and more than 10,000 steps per day). Clinically significant weight loss was observed and multi-component behavioral interventions (i.e., diet, exercise, and coaching) were most effective.
As noted in a previous study4, GLP-1 patients may benefit from additional support. Early empirical evidence7 suggests that pairing GLP-1 RA medications with health and well-being coaching for more sustainable lifestyle changes. A retrospective observational study (N = 115) investigated the effects of physician-, dietician-, and coach-supported behavioral changes in patients taking a semaglutide, tirzepatide, and liraglutide medication. Participants used a hyper-personalized tech-supported program that allowed for remote data monitoring. This hybrid approach to supporting behavior change (i.e., in-clinic visits and remote monitoring) yielded more active participation from patients. Over eight months, patients had an eight percent loss in weight from their starting point. Using a multi-prong approach bridged the gap for patients and led to weight loss while also helping patients build sustainable dietary and exercise behaviors.
Coaching GLP-1 Patients to Facilitate Dietary Behavior Change
Coaching could take many forms, one of which is working collaboratively with patients and opening a dialogue about their weight loss goals and a path forward for long-term weight loss.
Offering patients concrete, actionable behaviors can help them get on track with dietary lifestyle changes. The Dietary Guidelines for Americans (DGA)8, developed by the Departments of Agriculture (USDA) and Health and Human Services (HHS), provides health care providers, nutritionists, dieticians — and the public — with guidelines for nutritional requirements. These guidelines can help frame conversations with patients with type 2 diabetes and/or obesity while also offering specific parameters for nutrient intake. Another tool for health care providers and patients is the Healthy Eating Index (HEI). The HEI, developed in 1995 as a collaboration between the U.S. Department of Health and Human Services’ National Cancer Institute and the U.S. Department of Agriculture (USDA) Center for Nutrition Policy and Promotion1, measures how well Americans are following the recommendations set forth in the Dietary Guidelines for Americans (DGA).2
Updated every five years, the DGA and HEI align with the most up-to-date empirically-based nutrition recommendations, thereby informing evidence-based decisions in the context of dietary lifestyle and behavioral changes. It is important to work with patients to deepen their understanding of preferred foods and amounts while taking their GLP-1 medication so that, when they transition off their current pharmacotherapy for obesity or type 2 diabetes, there is a solid foundation built on nutrient-dense foods in place. Below is some quick-reference information from the DGA:
Caloric intake varies from patient to patient due to gender, age, daily activity level and their overall health status. However, the Dietary Guidelines for Adults offers parameters for caloric intake for persons at all stages of life:
| Gender | Daily Calories by Activity Level | ||
| Women | Sedentary | Moderately Active | Active |
| 19 – 60 years old | 2,000 – 1,600 | 2,200 – 1,800 | 2,400 -2,200 |
| Men | |||
| Men aged 19 – 60 | 2,600 – 2,200 | 2,800 – 2,400 | 3,000 – 2,600 |
Your patients’ caloric intake should be adjusted based on overall health and weight loss goals. Regardless of the recommended caloric intake, all adults should be sure to consume nutrient rich foods. Daily recommend nutritional essentials for adults aged 19-59 and adults aged 60+ are displayed below.
| Food Group | Adults 19 – 59 | Adults aged 60 and older |
| Vegetables (dark green vegetables, orange and red vegetables, beans, peas, lentils) | 2 – 4 cups per week | 2 – 3.5 cups per week |
| Fruits | 1.5 – 2.5 cups per day | 1.5 – 2 cups per day |
| Grains (e.g., whole grains, refined grains) | 5 – 10 ounces per day | 5 – 9 ounces per day |
| Dairy | 3 cups per day | 3 cups per day |
| Protein (e.g., lean meat, poultry) | 23 – 33 ounces per week | 23 – 31 ounces per week |
| Seafood | 8 – 10 ounces per week | 8 – 10 ounces per week |
| Nuts, seeds, soy products | 4 – 6 ounces per week | 4 – 5 ounces per week |
When a patient’s eating patterns do not include the recommended amounts of macronutrients, they are likely not meeting their daily requirements for protein and fiber, which are implicated in the preservation of lean muscle mass and cardiovascular health, respectively. Fiber and protein also promote satiety, so if GLP-1 RA patients are not losing weight, it might be diet related; they may not be choosing nutrient-dense foods.
Work with Patients to Identify Actionable Lifestyle Changes
As part of offering patients concrete guidelines such as those found in the DGA and HEI, it is also important to support patients by working with them to identify actionable strategies for implementing behavioral and lifestyle changes into their daily routine. Below is a summary actionable lifestyle changes:
- Modifying the home food environment: Encourage patients to leave fresh fruit in easy to see and easy to access places. Leave a bowl of oranges, apples, and bananas on the counter. If they prefer cold fruit, move the fruit bowl to a prominent place in the refrigerator. If patients keep cookies or chips on hand, encourage them to move them to a hard-to-reach place, like the back of the cabinet.
- Plan Meals: Have patients plan meals ahead of time and schedule time to cook into their daily routine. They may not need to cook every day — but they should plan to cook three healthy meals per week, leaving leftovers for lunch the next day or dinner another night. When patients make a grocery list, be sure to have them identify all the healthy options — legumes, lean protein, fruits, whole grains, healthy fats — and tell them to stick to the list. Following a balanced healthy diet can help manage blood pressure. Encourage patients to cook as many meals at home as they can so they have more control over what and how much they consume.
- Plan Exercise: Before patients go to bed, they should get their workout clothes ready and place them on their nightstand or in their bathroom so that they can change as soon as they wake. If they don’t have time for morning exercise, encourage your patients to still get their workout clothes ready so they can change into them when they get home from work. If patients join a gym or plan to meet friends after work for an exercise class or a walk in the park, they should pack a gym bag the night before and put it by the front door so they can grab it on their way to work. Or, better yet, have patients put their gym bag in their car after dinner.
- Mindful Eating: Bringing awareness to your patients’ eating habits is important to reduce or to extinguish non-preferred eating behaviors such as inattentive eating, eating when not hungry, or emotional eating — eating in response to negative feelings.10,11 Mindful eating, bringing our non-judgmental attention to our physical and emotional sensations when eating, is a useful strategy for helping us to determine whether we are eating because we are hungry or perhaps engaging in mindless eating behaviors.
- Temptation Bundling: Temptation bundling involves pairing an indulgence with an activity or behavior that yields delayed rewards.12 For example, going to the gym and riding the stationary bike while you watch the latest episode of your favorite TV show. Temptation bundling also mitigates present bias because it makes behaviors that are associated with delayed gratification — like exercise, for example — more gratifying in the present.12
- Sleep Hygiene: In the context of weight loss and weight maintenance, sleep hygiene and sleep quality are an often-overlooked strategy. When sleep quality is poor, we are at greater risk of associated health issues such as cardiovascular disease, type 2 diabetes, poor cognitive functioning, and weight gain.13,14 According to the Centers for Disease Control and Prevention15, sleep hygiene includes:
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- Going to bed at a consistent time each night
- Getting up at the same each day
- Optimizing your bedroom to ensure it is dark, quiet, relaxing, and the ambient temperature is comfortable
- Not keeping electronic devices such as smart phones, computers, and TVs in the bedroom
- Not consuming large meals, alcohol, or caffeine before bed
- Including exercise as part of your daily routine
A crucial element in achieving lasting behavior change is setting clear parameters and daily goals. Health care providers can play a pivotal role in this process by collaborating with patients to create realistic, actionable and sustainable behavior change plans. As part of a comprehensive treatment program, incorporating a Low Calorie Diet (LCD) or Very Low Calorie Diet (VLCD) from Robard Corporation could be highly beneficial. These programs offer proven patient education protocols and scientifically formulated meal replacements, ensuring that nutritional needs are met while supporting the journey toward healthier habits. Further, combining GLP-1s with quality meal replacements helps to ensure long-term success and safety for patients — and creates a business growth opportunity for practitioners.
Source(s):
2 Health and well-being coaching adjuvant to GLP-1 induces weight loss
5 Health and well-being coaching adjuvant to GLP-1 induced weight loss
6 Behavioral lifestyle interventions for moderate and severe obesity: A systematic review
9 How much fiber should I eat?
10 Mindfulness, eating behaviours, and obesity: a review and reflection on current findings
11 Emotional eating and obesity in adults: The role of depression, sleep and genes
12 Teaching temptation bundling
13 The National Sleep Foundation
14 Sleep is essential to health: an American Academy of Sleep Medicine position statement
15 Centers for Disease Control and Prevention: Tips for better sleep
About the Author: Dr. Dawn M. Sweet has over 20 years of experience in the field of communication. Dr. Sweet has given several invited talks to and workshops for academic and private sector audiences on the role of nonverbal and verbal communication in achieving positive outcomes and mitigating bias. Her research has been published in several top ranked peer-review journals, and it has been featured on NPR’s River to River / All Things Considered, Buzzfeed, and Science Daily. Her research has also been used to inform expert testimony.
About Robard: Robard Corporation’s medical obesity treatment programs and scientifically-designed nutrition products have been utilized by physicians, surgeons and hospitals across the United States to successfully treat patients living with obesity. To learn more about us and how we can help your practice and patients, visit us online at www.Robard.com, email us at info@robard.com, or call (800) 222-9201.
