Health and Well-Being Coaching Adjuvant to GLP-1 Induced Weight Loss

Abstract

Glucagon-like peptide agonists (GLP-1) are highly effective anti-obesity medications. However, sustained effectiveness is potentially plagued by lack of adherence to the drug and resumption of pre-weight loss behaviors. Side effects are primarily severe gastrointestinal distress but can occasionally be more serious. Health and well-being coaching (HWC) is an important obesity intervention that can be used alongside GLP-1 prescription. HWC is documented to improve medication adherence and promote healthy behavior change. A coach who understands the complexities of rapid weight loss, specifically with GLP-1, can help the patient persist with the treatment. Moreover, the coach can assist in navigating GLP-1 side effects including undesirable loss of skeletal muscle during the weight loss period. A patient-centric and collaborative relationship seem essential to the HWC process. Specific coaching techniques are suggested for working with patients losing weight. The logical, but yet to be tested, expectation is that HWC as an adjuvant intervention to GLP-1 prescription will improve medication adherence and encourage sustained weight loss and health benefits in patients with obesity.

“A strong patient-centric coaching relationship and key coaching skills are essential to an effective intervention.”

Introduction

The prevalence of obesity and related health consequences are well documented ¹ with the American Medical Association recognizing obesity as a chronic disease in 2013. As this epidemic has spread over the last century, so have attempts to curb this disease and its adverse effects. Behavior change, medications, and surgical techniques each show some success in treating obesity. Unfortunately, shortcomings of weight loss strategies prove difficult to overcome and limit application, effectiveness, or widespread utilization. Weight recidivism or regain is common after these efforts, resulting in a long and unsuccessful road of disappointment for the patient with obesity. ²

Recently, another class of medications (GLP-1 or glucagon-like peptide-1 receptor agonists) received FDA approval to treat obesity. ³ GLP-1 is a peptide released by gut enteroendocrine cells after a meal. ⁴ Its action enhances insulin and inhibits glucagon secretions resulting in regulation of blood glucose levels. Other effects include appetite suppression, decreased cravings, and increased satiety. ⁵ Popular GLP-1 agonist medications are marketed and sold under the brand names Ozempic, Wegovy, Mounjaro, and Zepbound and are described in Table 1. These medications differ in mechanism of action, as Mounjuro and Zepbound also activate glucose-dependent insulinotropic polypeptide [GIP] receptors classifying them as dual GLP-1/GIP agonists. However, in this paper we simply use GLP-1 to refer to both single and dual receptor agonists.

Table 1.

Most Popular FDA-Approved Injectable GLP-1 Agonists Available by Prescription.

Generic Name	Brand Name	Indication	Dosing	Administration	Manufacturer
Semaglutide	Ozempic	Diabetes	0.25, 0.5,1.0, 2.0 mg	Injection Weekly	Novo Nordisk
Semaglutide	Wegovy	Obesity	0.25, 0.5, 1.0, 1.7, 2.4 mg	Injection weekly	Novo Nordisk
Tirzepatide	Mounjaro	Diabetes	2.5, 5.0, 7.5, 10.0, 12.5, 15.0 mg	Injection weekly	Eli Lilly and Company
Tirzepatide	Zepbound	Obesity	2.5, 5.0, 7.5, 10.0 12.5, 15.0 mg	Injection weekly	Eli Lilly and Company

Results from drug trials support claims that GLP-1s are different than other weight loss medications, not only in terms of mechanism of action but also health benefits. In a 17-month study, weight loss up to 20% of total body weight occurred with over 85% of patients achieving clinically meaningful weight loss, indicating a high effectiveness for GLP-1 treatment. ⁶ Additionally, other reported benefits include pancreatic beta cell proliferation, lowering of blood pressure and cholesterol, improved cardiac function, and lower risk of cardiac events. These are substantial side benefits affecting key factors in diabetes, renal disease, heart disease, and stroke. In fact, GLP-1 prescription is said to lessen incidence and severity of these conditions and result in improved morbidity and mortality.^7-9 While these findings are early in our understanding, this is truly remarkable and has resulted in GLP-1 being lauded as the next miracle medication. Given the hundreds of millions of obese patients worldwide, and more than 100 million in the U.S. alone, we can expect tens of millions of GLP-1 prescriptions to be initiated over the next decade. Before FDA approval specifically for obesity, off-label prescription for weight loss created GLP-1 shortages for patients with diabetes. Demand is so great for these medications that companies who manufacture them have started building new, or expanding existing, factories dedicated to their production. ¹⁰ Moreover, patients should be made aware that compounded formulations are becoming increasingly available and are often not the same drug as produced by manufacturers. ¹¹

With all the upside potential for GLP-1, we must ask, is there any downside? Are they really that effective? Are there any risks or unwanted side effects? Should not all obese patients without contraindications (see link to the Ozempic label below) be prescribed these wonder drugs?

It’s worth noting that FDA approval of both semaglutide and tirzepatide came with the indication that these medications were an adjunct to a reduced caloric diet and increased physical activity. ³ However, in practice, support for lifestyle medicine and behavior change is not typically included in GLP-1 prescriptions. The purpose of this paper is to introduce health and well-being coaching (HWC) as an ancillary intervention to support behavioral and lifestyle change for patients using GLP-1 medications. First, we present the shortcomings of GLP-1 medications that accentuate the need for lifestyle medicine intervention. Then we discuss how lifestyle changes can help address certain problems associated with GLP-1 use. Finally, HWC is introduced as a meanigful intervention for successful GLP-1 induced weight loss and maintenance. The objective here is to help the clinician and health coach understand the challenges of GLP-1 prescription, and how HWC can support these patients to beneficial behavior change and sustainable health benefits.

Shortcomings of GLP-1 Prescription

It seems reasonable to say that GLP-1 prescription does not cure obesity but treats it much as a blood pressure medication attenuates hypertension. Remove the medication, and, in the absence of meaningful ongoing lifestyle medicine intervention, weight regain will occur in the obese patient as sure as chronically high blood pressure will return in the hypertensive patient. The Step 1 Trial ¹² found using GLP-1 for more than 1 year resulted in a loss of 15.3 kg or 14.9% of initial body weight. Another study of GLP-1 use, for over 20 weeks, showed approximately 10% (11 kg or 23 lbs) weight loss. ¹³ Continued use of GLP-1 for almost another year resulted in 8% further loss of body weight while changing to a placebo resulted in gaining most of the weight back. In fact, a follow-up to the Step 1 Trial showed participants had regained two-thirds of weight loss within 1 year of stopping GLP-1 treatment. ¹⁴ The endpoint of weight regain has long been the shortcoming of weight management strategies. Less effective drugs than GLP-1 have seen similar weight regain challenges and it is well accepted that yo-yo dieting is the bane of the obese patient. ¹⁵

While the answer seems simply to continue using the medication, it turns out most real-world patients on GLP-1 do not persist for more than 3 months. In fact, a recent report from Blue Cross Blue Shield Association followed 169 000 patients and found only 42% were still on their GLP-1 at 12 weeks. ¹⁶ A similar real-world study of commercially insured patients with obesity, ¹⁷ showed less than 33% were still adhering to GLP-1 prescription at 1 year making most patients who begin using GLP-1 prone to weight regain. One reason for discontinuing GLP-1 use may be expense-related. In the U.S., GLP-1 prescriptions can cost over $1000 a month with the prospect for lifetime need. Medicare is likely to begin closely scrutinizing GLP-1 prescription requests as their costs have sky-rocketed with the recent approval to treat obesity. ¹⁸ If a patient is lucky enough to have reimbursement, there is still the probability of weight loss plateau which seems to accompany most every means of weight loss. ¹⁹ Moreover, there are a myriad of unwanted side effects that can impact medication persistence.

Over 95% of patients using GLP-1 medications report adverse events. ²⁰ Gastrointestinal distress is the most common side effect reported by more than 80%. Constipation, diarrhea, and vomiting are more commonly seen with GLP-1 use than with a placebo. Many of these intestinal side effects are more likely to occur during the early, dose-escalation phase of GLP-1 utilization. ²¹ Gall bladder and pancreatic flair ups are also reported at a slightly higher rate with GLP-1. With GLP-1 use, headaches and reports of fatigue are observed at twice the rate seen with a placebo. An increase in dermatological events, including alopecia, is documented with GLP-1 use. ²² Using novel, but less controlled methods, a search of YouTube, Reddit, and TikTok, found mental health issues and insomnia also are frequent complaints with GLP-1 use. ²³ Kidney problems, changes in vision, hypoglycemia, and allergic reaction are additional, though rare side effects listed on the Ozempic label (https://www.ozempic.com/how-to-take/side-effects.html). While most side effects are not severe and can be effectively managed, there is little doubt that chronic occurrence can contribute to poor drug adherence or cessation of medication.

Rapid weight loss, regardless of how it is attained, is typically a combination of fat and muscle mass. While fat loss is the purpose of the intervention, losing muscle is often an undesirable effect of weight loss. ²⁴ Of the weight lost with GLP-1 mediations, 25%–40% might be from muscle mass.^5,13,14 Loss of muscle leads to reductions in strength and balance, increasing the risk of fatigue, lower bone density, and injury. This is a potentially more serious problem in older adults, who already have a greater risk of osteoporosis, sarcopenia, and related falls because of the aging process. ²⁵ Again, loss of muscle mass is a function of rapid weight loss and not specific to GLP-1, but this issue must still be considered a potential downside to using these highly effective medications. Companies that produce GLP-1 are concerned about sarcopenia-related effects and have started seeking pharmaceutical solutions to the problem. ²⁶ Fortunately, much of the loss of muscle with rapid weight loss can be avoided if lifestyle behaviors, particularly regular exercise, are adopted during the weight loss program. ²⁴

Lifestyle Changes Along Side GLP-1 Prescription

There is not only a high probability of weight regain within 2 years after substantial GLP-1 induced weight loss, but it is also likely a less favorable body composition will occur. Without an evidence-based plan, weight regain does not spontaneously include muscle mass replacement. When a patient returns to their former weight, they add back fat mass but may also replace some of previously lost muscle mass with fat as well. Can this be avoided with lifestyle adjustments? Specifically, can behavioral changes to nutritional and physical activity habits attenuate weight regain and improve the ultimate body composition profile of the patient?

High protein diets can be employed with the intention of maintaining fat free mass during an intense weight loss period. ²⁷ The recommended daily intake or allowance (RDI or RDA) for protein in healthy adults is .8 g/kg body weight. While this is adequate for most people, there are indications that ingesting a higher level of protein (1.4-2.4 g/kg body weight) during a weight loss period can help maintain lean body mass, and probably skeletal muscle mass, compared to lower protein intake. The elderly are especially prone to losing muscle mass with caloric deficit but may also benefit from increasing the amount and quality of protein in their diet. ²⁸ As an example of protein quality, the amino acid leucine is essential to muscle protein synthesis and should be considered in dietary planning. Many of the relevant nutritional studies of protein intake also included a physical activity component for the treatment group. ²⁷

It is a long-standing recommendation to use exercise to preserve muscle mass during a weight loss program. This tenet has come under scrutiny recently and has emerged unshaken. ²⁴ Using DEXA scans, these authors detected significant loss of lower extremity muscle mass after a 7% weight loss. This loss of lean body mass was substantially attenuated when endurance (cardiovascular) exercise was added to the weight loss program. Moreover, using resistance (strength-training) exercise during intermittent fasting leads to loss of fat mass but with the preservation of muscle mass. ²⁹ Accordingly, both endurance and resistance exercise training are proven effective in the effort to retain muscle mass during weight loss. Resistance exercise has been recently recommended to preserve lean body mass during GLP-1 use. ³⁰ A recent Danish study, demonstrated exercise combined with GLP-1 treatment was most effective at maintaining weight loss and body composition after GLP-1 treatment termination. ³¹ In fact, on follow-up, though weight was regained after GLP-1 termination, body weight and composition were maintained after termination of the supervised exercise program. The existing evidence supports a recommendation for starting an exercise program while using a GLP-1 medication as the best recipe for predicting long-term weight loss and body composition success. Emerging recommendations for exercise prescription to achieve holistic health in patients using GLP-1 are beginning to appear.^32,33

In addition to protein intake and exercise habits, several other lifestyle modifications may help the weight loss and maintenance efforts of those using GLP-1 medications. For example, there is preliminary evidence that post-menopausal women benefit from adding hormone therapy to optimize the GLP-1 effect on weight loss. ³⁴ Furthermore, to help avoid gastrointestinal distress a multi-disciplinary expert panel recently recommended eating only when hungry, eating slowly, stopping eating when full, and avoiding lying down or excessive activity after a meal. ²¹ They also recommended eating more frequently, paying careful attention to maintaining hydration, avoiding overly sweet, spicey, or fatty foods, and not drinking through a straw. While generally relevant, they said these recommendations are especially important in the first few days following each GLP-1 injection.

Other experts, including physicians with experience prescribing GLP-1, recommend creating a healthy home environment with only high-quality foods. ³⁵ Furthermore, journaling diet, exercise, and sleep habits (i.e., what, how much, and when) during a successful weight loss period with GLP-1 can be beneficial to long-term patient success. Such a journal can create a “habit template” to be applied over a lifetime. Patients must also understand that appetite will increase with drug cessation, and slowly weaning off GLP-1 may help rather than simply stopping the drug completely.

When treating obesity, is essential to recognize the critical importance of the brain in regulating multiple hormones and hormone pathways involved in cravings, appetite, and satiety. The management of obesity, therefore, involves optimizing physical as well as mental and emotional regulation. Addictive eating behaviors, also referred to as food addiction, exemplify the close body-mind interrelationship. Some foods may trigger an addictive process resulting in the brain’s dopamine-modulated reward circuits behaving as if exposed to drugs of abuse. ³⁶ Food addiction researchers have demonstrated complex alterations in neural and behavioral food reward functions that are triggered by food cravings. ³⁷ Food cues, for instance, can increase brain metabolism in the orbitofrontal cortex inducing food-seeking behavior, especially for glucose and high fat. ³⁸ The addictive eating behaviors of many obese patients originate from the same reduction in dopamine 2 receptors and consequent lower activation of the reward center as those with drug or alcohol dependency. ³⁹ GLP-1 medications can result in beneficial cardiometabolic outcomes such as improved insulin sensitivity and blood glucose levels but the individual with obesity still has entrenched underlying addictive behavioral patterns. These addictive pathways can be overcome with the steady development of new neural networks associated with self-regulation and healthy behavioral patterns. ⁴⁰

From the initiation of GLP-1 treatment, it is imperative is to manage both body and mind. It is therefore vital that the individual with obesity has in place a comprehensive support team providing mental/emotional as well as physical treatment strategies. By addressing these long-standing eating behaviors and their consequent biological sequelae, a sustainable healthy lifestyle foundation can be better established.

It seems logical that a multi-disciplinary health care team for obese patients using GLP-1 medications will include a dietician and exercise professional. A dietician can improve healthy eating habits and an exercise physiologist can optimize exercise programming. While 12 weeks of diet and exercise counseling in obese patients can bring about a 6%–7% weight loss, ⁴¹  weight regain is common in the following year.^19,41 However, adding GLP-1 after lifestyle counseling can promote another 15%–20% loss of weight in the subsequent year. ⁴¹ In the landmark tirzepatide (Mounjuro and Zepbound) study, there was only a 3% loss of body weight for the placebo/lifestyle counseling group while the GLP-1 groups experienced 15%–20% loss over the same 72-week treatment period. In other words, lifestyle counseling alone did not promote substantial weight loss in most obese patients. One study demonstrated lifestyle counseling with or without GLP-1 resulted in substantial weight regain in the year after the treatment period. ¹⁴ This should come as no surprise as it is well understood that changing lifestyle habits is difficult, and lack of adherence to the best plans often results. ¹⁹ HWC is an intervention to help overcome these problems and is proven effective in studies with obese patients. ⁴²

Health and Well-Being Coaching to Support Lifestyle Change with GLP-1 Prescription

There is strong clinical evidence that HWC can assist patients in their efforts to lose weight and maintain weight loss through healthy lifestyle behaviors.^43,44 There is also preliminary evidence for integrating GLP-1 with HWC for beneficial lifestyle changes. ⁴⁵ Moreover, HWC is shown to facilitate patient medication adherence as documented via pharmacy claims. ⁴⁶ If lack of adherence to prescription, and weight regain due to resuming prior lifestyle habits are the largest obstacles to GLP-1 program success, then a reasonable hypothesis is that HWC can improve long-term effectiveness of these medications. There are also indications that greater contact with a health care professional improves GLP-1 persistence. ¹⁶ It is unlikely that most prescribing physicians will find adequate time for meaningful follow-up with many, if any, of their patients with obesity. However, referral to a HWC professional may be an excellent substitute and, in 2024, the Centers for Medicare and Medicaid Services (CMS) temporarily approved HWC on the Medicare Telehealth Services list. ⁴⁷ While there are many successful studies of HWC interventions for obesity, ⁴² there is limited information about specific HWC strategies to apply when working with obese patients using GLP-1. Some useful guidance for coaches comes from a 3-month HWC intervention of parents suffering with obesity. ⁴⁸ This paper used a qualitative approach to identify critical considerations for HWC while working with patients with obesity. The clinical professional/coach is encouraged to access this resource; here are key points from this work:

Relationship

Both coaches and patients with obesity in this study agree a key element for effective treatment is a collaborative alliance built on trust, openness, listening, and self-awareness. ⁴⁸ The importance of co-creating the coaching relationship while adapting to patient needs was essential to the HWC process.

Coaching Tools

Themes from interviewed coaches included using open-ended questions, active listening, and reflections as essential to the process. Being genuinely curious and focusing on the whole life of patients (not only obesity) proved important coaching strategies. Respecting the patient as a resource, particularly as a source of creative solutions, was an important outcome of this client-centered attitude. Encouraging patients to keep daily self-reflection journals while fostering deeper understanding of factors and feelings contributing to avoidance, or engagement, in certain behaviors was also beneficial. The coach explains to the patient that these tools and behavioral activities are designed to build self-awareness and self-reflections skills to enable better self-management as their treatment continues. ⁴⁸

Insights for Coaches to Build On

Patients are helped to understand they are whole persons, not just labeled or defined as patients with obesity. It is useful to develop strategies for handling overwhelming aspects of their life, along with cultivating better self-esteem and self-confidence. Creating a psychologically safe space in a trusting alliance with patients is critical; it’s also important to be careful to not push the patient ahead any faster than they want to go given their recognized stage of readiness to change. Do not rush and trust the weight loss issue will naturally come up. It follows that active listening is an important skill, but this must be done with compassion and without judgment. Expand the focus from improving diet and physical activity to working with all aspects of life to best understand where changes are needed. ⁴⁸ It may also be helpful to focus on lifestyle changes for improvements in cardiometabolic risk factors such as blood pressure, cholesterol, and blood glucose, which can result even in the absence of significant weight loss. ⁴⁹

Positive Experiences for Patients

Patients reported prioritizing themselves and their self-care. They said they were experiencing improved mental well-being. Patients developed the capacity to take charge of their lives and improve their daily routines. They created a beneficial daily schedule and a healthier living environment for their family. ⁴⁸

Positive Experiences for Coaches

Coaches reported this work as meaningful and challenging while having mostly positive experiences during the 3-month intervention. They felt they were making an impact in their patients’ lives. Coaches looked forward to coaching sessions and using their coaching tools. ⁴⁸

Many of the main points from Karmali et al are echoed in a study of picky eaters. ⁵⁰ This paper emphasized the importance of a supportive coaching relationship focusing on development of autonomous choice, confidence, and readiness to change. As for coaching tools, Matthews ⁵⁰ recommended using appreciative inquiry, motivational interviewing, SMART goal-setting, change-scales, and mindfulness as key to the HWC process. He added positivity and gratitude, while recognizing small steps, were valuable coaching skills. When working with patients with obesity, the savvy coach will make use of the advice from these studies^48,50 as summarized in Figure 1. However, the coach must also recognize the unique aspects of working with patients prescribed GLP-1 medications for weight loss.

Figure 1.

Tools and strategies for coaches assisting patients using GLP-1.

For the knowledgeable HWC professional, it will be essential to understand and work to minimize GLP-1 side effects while appreciating the patient’s temptation to discontinue the medication. The coach should be prepared to problem-solve and brainstorm solutions to medication-adherence related problems. Topics related to managing and using an injectable medication should be expected discussion points. ⁵¹ Furthermore, the effective coach will coordinate with a patient’s health care team as they cease or taper GLP-1 use, possibly 1-2 years after starting the medication. ⁵² The coach should understand the potential for harmful loss of muscle mass and the real possibility of weight regain. These issues are discussed above, in the sections on medication shortcomings and lifestyle change. HWC processes integrating technology (e.g., smartphones, web platforms, connected scales, and wearables/devices such as activity trackers) to assist coaches with patient compliance and tracking, can improve effectiveness and may become essential in qualifying for third-party reimbursement.

The progressive coach must keep up with the fast-changing landscape of GLP-1 information. The research for these medications, and support for this work, is currently very intense and evolving on an almost daily basis. The coach must stay vigilant in tracking important GLP-1 developments which might affect their patients. Moreover, additional anti-obesity medications are under investigation and coaches should be aware of related developments when and if new drugs come to market. Comparative effectiveness studies of HWC adjuvant to GLP-1 treatment in patients with obesity are warranted and likely forthcoming soon. Engaged coaches should be aware of this work and be in the best position to help their patients using GLP-1 and other weight management medications.

Summary, Conclusions, and Takeaway Points

The GLP-1 revolution is upon us and millions of patients will be prescribed these medications in the next 5-10 years. GLP-1 use promises substantial weight loss and a myriad of other health benefits with most these claims increasingly supported by research evidence. It is likely HWC professionals will soon be working with patients using GLP-1 medications if they are not already.

Most patients who start GLP-1 medications will discontinue use, and without meaningful behavior change, there is a high probability of weight regain. Lifestyle and mindset changes are vital for GLP-1 patients and HWC is an intervention option demonstrated to benefit patients with obesity. There are specific HWC tools and strategies to emphasize when working with obesity. A strong patient-centric coaching relationship and key coaching skills are essential to an effective intervention.

GLP-1 medications are proven effective and will be highly successful obesity treatments for many patients over the initial 12-24 months. However, this short-term success is optimally used to catapult the patient to sustained long-term health and well-being. Behavior changes and sustained lifestyle habits are essential to long-term GLP-1 prescription success. HWC is expected to be an effective adjuvant intervention to GLP-1 treatment, making sustainable achievement of weight loss and health goals more possible than ever before.

ORCID iDs

Gary A. Sforzo https://orcid.org/0000-0002-2346-4751

Neil F. Gordon https://orcid.org/0000-0002-9450-0326

Margaret Moore https://orcid.org/0000-0002-2801-2287