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Lifestyle approaches to consider when using GLP-1 medications

By: Richard Bloomer

The Obesity Epidemic 

The quest for the perfect body—or at least one that looks and feels healthy—is a regular pursuit for millions of  individuals each day. Unfortunately, the evidence tells us that many men and women struggle to develop and  maintain their desired physique, despite the billions of dollars spent annually on products and programs  promising to deliver amazing results pertaining to weight/fat loss and muscle gain. 

Unfortunately, a significant number of individuals living in developed countries today are classified as  overweight (body mass index [BMI] of 25-29.9 kg/m2) or obese (BMI ≥30 kg/m2). According to the Centers for  Disease Control and Prevention, an estimated 42% or more of the United States population is now categorized  as obese, with close to 70% considered either overweight or obese.  

Combatting obesity is important, not only to improve quality of life (Kolotkin and Andersen, 2017) but also to  reduce the economic burden to the healthcare system. For example, a 2021 study noted higher annual medical  care costs for those who are obese versus normal weight—$2505 per year with costs increasing significantly  with class of obesity, from 68.4% for class 1 to 233.6% for class 3 (Cawley et al., 2021). That is, the higher the  BMI of the person, the greater the medical costs. When considering the increase prevalence of obesity, the  annual costs in the United States alone is approaching $300 billion. This is unfortunate, as in most cases of  obesity, the problem can be avoided. 

Weight Loss Drugs 

While a change in lifestyle should be encouraged as the best long-term approach to combating obesity, many  people seek alternative approaches as the first-line defense. Most recently, this includes the use of prescription  medication in the form of glucagon-like peptide-1 (GLP-1) receptor agonists, such as semaglutide (e.g.,  Wegovy®), which was recently approved by the US Food and Drug Administration for chronic weight  management (Chao et al., 2023). The good news is that, for most users, the medication works—resulting in  weight loss and improved glucose metabolism.  

Semaglutide appears effective and acts in a number of ways (Alanazi et al., 2024), including a slowing of the  movement of food from the stomach into the small intestine, a brain-mediated appetite suppression, and a  reduction in secretion of the hormone glucagon. Because glucagon serves the purpose of increasing blood  glucose, a reduction in this hormone results in lower glucose and better glucose homeostasis. All of the above  may help with weight loss over time.  

The clinical trial data are convincing, with subjects losing a considerable amount of weight—adverse events  (specifically, gastrointestinal) notwithstanding (Bergmann et al., 2023). There has been so much talk about this  drug recently, and others like it, that the manufacturers are having a difficult time keeping up with the demand.  In fact, popularity has grown so much that many employers are now covering weight loss drugs as a part of  health benefits. 

Wegovy® is a variant of the popular diabetic drug, Ozempic®—both produced by the Danish drugmaker, Novo  Nordisk. These drugs are not the only medications gaining popularity for their weight loss effects, as demand is  now also increasing for Mounjaro, a diabetes medication that promotes weight loss (Gettman, 2023), using a  different key ingredient, tirzepatide. With the overwhelming interest in these drugs, it is not at all surprising that others are currently under development.  

Effectiveness 

These drugs are of interest clinically because they help produce significant weight loss and may provide  additional benefits such as lowering blood pressure, blood sugar, and blood cholesterol (Di Folco et al., 2022).  A study published in the New England Journal of Medicine noted a nearly 15% reduction in body weight  following 68 weeks of treatment with once weekly semaglutide (2.4 mg), plus lifestyle intervention (Wilding et 

al., 2021). A more recent publication by the same group noted a significant reduction in BMI for obese  adolescents (Weghuber et al., 2022). However, patients should be instructed by the prescribing physician to  engage in lifestyle modification (e.g., reduced calorie diet and increased physical activity) simultaneously with  use of the drug, as noted on the company website.  

Potential Concerns 

While people focus on the positive effects, it is important to understand the potential side effects of using  weight loss drugs. For Wegovy® semaglutide, the most common side effects include the following: nausea,  diarrhea, vomiting, constipation, stomach (abdomen) pain, headache, tiredness (fatigue), upset stomach,  dizziness, feeling bloated, belching, low blood sugar in people with type 2 diabetes, gas, stomach flu, heartburn,  and runny nose or sore throat. Other more serious side effects are noted on the company website. 

Aside from the above, weight regain is a concern with the cessation of use of the medication. This reality has  been shared by former semaglutide users in anecdotal accounts and confirmed by a large-scale clinical trial  (Robino et al., 2021). In this study, 803 subjects who received the drug for an initial 20 weeks (and experienced  an average weight loss of 10.6%), were then assigned to either continue with the drug for an additional 48  weeks or to be switched to use a placebo for the remaining 48 weeks (lifestyle intervention to be followed by  subjects in both groups). It was noted that those subjects assigned to the continued drug treatment lost an  additional 7.9% of body weight, on average. However, those assigned to the placebo gained 6.9% body weight,  on average.  

In addition, the authors addressed the long-term side effect profile by stating that “Gastrointestinal events were  reported in 49.1% of participants who continued subcutaneous semaglutide vs 26.1% with placebo.” Individuals  might ask why the placebo treatment would lead to GI events (e.g., nausea, vomiting, diarrhea). Remember that  

in this study, all subjects received the semaglutide for the initial 20 weeks and then were randomized to either  continued drug use or placebo. The 26.1% of subjects reporting adverse events could be due to residual  problems stemming from the initial 20 weeks of treatment or could possibly be unrelated to treatment. Beyond  this, mental health side effects are possible, including anxiety, depression, and suicidal ideation and attempt.  Those contemplating use of semaglutide should consider the possible adverse effects of use and discuss these  with their physician.  

The bottom line related to the use of semaglutide is that the drug does work to facilitate weight loss, and in  some individuals, the amount of weight loss can be substantial. There is a rapid and continuous decline in  weight through the initial year of drug use (amounting to approximately 15% of body weight; equating to close  to 30 pounds for those with a starting weight of 200 pounds), followed by a stabilization, assuming continued  treatment (Garvey et al., 2022). The necessity for continued use should be expected if desiring weight  maintenance, as this is the case for all weight loss interventions, including physical activity and dietary  manipulation.  

Lifestyle approaches 

If aiming to adopt a lifestyle approach to combat increased body weight and to improve health, it is best to  identify people who can assist with direction and goal setting. Two important people in this situation include a  registered dietitian/nutritionist who can assist with the dietary manipulation and planning, as well as an exercise  physiologist and/or personal trainer who can assist with the exercise prescription and encourage a change in  attitude towards exercise (McClaran, 2003). Beyond this, set goals for nightly sleep, with the understanding that  obtaining adequate and quality sleep is important in the quest for losing weight and maintaining weight loss  (Papatriantafyllou et al., 2022). 

Exercise 

When it comes to shedding body weight and fat, physical activity and structured exercise are effective methods  (Bellicha et al., 2021), as both contribute to overall energy expenditure. This will create an energy deficit when  coupled with reduced calorie intake. Attempts should be made to increase daily physical activity such as 

walking, housework, and yardwork. Although these activities are of lower intensity than structured exercise,  they do expend energy and can prove helpful. Structured exercise such as running, swimming, and weightlifting  not only expends calories, but also improves cardiorespiratory fitness, muscle strength and endurance, as well as  metabolic health—which assists with weight loss and maintenance over time.  

For cardiovascular exercise, those serious about weight loss should aim for a minimum of three hours per week,  divided over three or more days. This form of exercise includes jogging, cycling, stepping, swimming, and  similar activities—yielding approximately 80-100 calories “burned” per 10 minutes of moderate to high  intensity activity for most individuals. For resistance exercise (weight lifting), the goal should be approximately  1.5 hours per week, divided into 2-3 sessions—splitting the body parts into different days, to allow for adequate  recovery between sessions. Resistance exercise will also expend energy but to a lesser degree as compared to  cardiovascular exercise (assuming matched intensity). However, resistance exercise will help to develop muscle  mass, which can slightly raise the overall metabolic rate (how many calories someone expends at rest). If the  goal is weight loss and maintenance, with few exceptions, both cardiovascular and resistance training should be  performed by all individuals.  

Nutritional Intake 

As important as physical activity and exercise are to weight loss and maintenance, it can be argued that dietary  intake is more important. This is because it takes quite a significant effort to expend 1000 calories through  exercise (about two hours of hard work for most individuals), but those same 1000 calories (or more) can be  easily consumed in one fast-food meal. Therefore, paying close attention to nutritional intake is of vital  importance.  

While it seems simple, and an overwhelming number of different approaches exist (Smethers and Rolls, 2018),  to lose weight individuals should consume fewer calories each day than they expend. The goal for many is 10- 20% less calories than maintenance needs. Beyond the number, the type of calories is important, with the goal  of consuming a nutrient-dense diet of high quality protein (e.g., white meat of chicken and turkey, lean pork and  red meat, cottage cheese), low glycemic index carbohydrate (e.g., beans, whole grains, most vegetables, some  fruits), little to no sugar (including sweetened beverages), low to moderate amounts of fat (but adequate  essential fatty acids), and a high volume of water (~1 gallon per day).  

While caloric restriction is generally viewed as the standard method for weight loss, other plans have proven  successful in recent years—including intermittent fasting (IF) and the ketogenic diet. With IF, individuals may  not modify the type of foods or how much is consumed, but rather, when foods are consumed (usually during a  6–8-hour feeding window during the day). With the ketogenic diet, carbohydrate intake is reduced significantly  (usually < 30 grams per day). This prompts the body to produce ketones in the liver from stored body fat,  resulting in significant weight loss over time.  

Finally, adequate sleep is essential for maintaining overall health, including gut health, and may help to  minimize potential disruptions in GLP-1 signaling pathways. Therefore, aiming for consistent nightly sleep is  important.  

Actions to Support GLP-1 Receptor Agonist Users 

For GLP-1 receptor agonist users and with consideration for the possible nutritional needs with medication use,  the inclusion of select dietary supplements may be helpful. These would be for purposes of supporting 1) gut  health, 2) muscle recovery, 3) other nutrient needs—with reduced calorie intake this becomes more of a  concern, and 4) hydration—as a recently published pharmacovigilance study concluded that certain GLP-1  receptor agonists (liraglutide, dulaglutide, semaglutide, and tirzepaptide) have the potential to induce  dehydration, which necessitates special attention (He e al., 2024).  

Supplements that may be helpful include items such as prebiotics, probiotics, and digestive enzymes to aid gut  health, essential amino acids to aid muscle recovery, the typically recommended vitamins and minerals, and 

electrolytes. Of course, consultation with a qualified healthcare practitioner is always recommended prior to  starting any new dietary supplement regimen. Moreover, obtaining the majority of nutrients from whole food is  preferred, in addition to high volumes of water, with inclusion of dietary supplements as a means to compliment the whole food intake. 

Conclusion 

Obesity is an ongoing problem in the United States and in most developed nations around the world. As is  typical, people desire a quick-fix approach to weight loss. Most recently, attention from both doctors and  patients has shifted to weight loss drugs—GLP-1 receptor agonists to be specific. While these drugs can be  highly effective in terms of weight loss, they can promote undesired side effects, which must be carefully  evaluated and considered prior to use. For those who currently use GLP-1 receptor agonist drugs and would like  to support their gut, muscle recovery, and overall health—they might consider the use of select nutrients,  including probiotics, essential amino acids, vitamins and minerals, and electrolytes.  

Content in this article and on this site is provided for informational purposes only. It is not meant to substitute for  medical advice from your physician or other medical professional. You should not use the information contained  herein for diagnosing or treating a health problem or disease, or for prescribing any medication. The statements in  this article have not been evaluated by the Food and Drug Administration. Supplements mentioned are not  intended to diagnose, treat, cure or prevent any disease.

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