Abstract
Background
Glucagon-like peptide-1 receptor agonists (GLP-1RAs) drug-induced weight loss is associated with fat mass reduction but can also lead to nutritional deficiencies and loss of muscle. We quantified nutritional deficiencies in adults who had undergone GLP-1RA treatment.
Methods
This was an observational, retrospective analysis of de-identified patient-level claims data from 461,382 adults newly prescribed GLP-1RAs between 7/2017 and 12/2021 with no prior diagnoses of nutritional deficiencies. While most patients had type 2 diabetes (T2DM), the population also included individuals with type 1 diabetes (T1DM), prediabetes, or no recorded diabetes diagnosis. A secondary propensity-matched analysis compared GLP-1RA users with non-users. The matched comparator cohort consisted of adults with type 2 diabetes treated with metformin but not prescribed GLP-1RAs, whereas GLP-1RA users were treated with both metformin and GLP-1RA. Nutritional deficiencies were assessed at 6 and 12 months after GLP-1RA initiation. Nutritional deficiency diagnoses or complications were compared between patients with or without a dietitian visit within a 6-months of treatment initiation.
Results
Patients were mainly female (56.3 %), mean age (±SD) 52.9 (±11.7) years, with obesity (44.9 %) or overweight (5.6 %); type 2 diabetes (80.5 %) and hypertension (66.3 %) were the most common comorbidities. Nutritional deficiencies were diagnosed in 12.7 % of the patients within 6 months after GLP-1RA initiation and in 22.4 % within 12 months. Vitamin D deficiency was most common, having an incidence of 7.5 % and 13.6 % within 6 and 12 months, respectively. Recorded nutrient deficiencies or deficiency-related complications were more likely among patients with a dietitian visit within the first 6 months of GLP-1RA initiation compared to patients without a dietitian visit.
Conclusion
Over 20 % had nutritional deficiencies diagnosed within one-year of starting GLP-1RA treatment. These findings highlight the importance of nutritional screening and diagnosis of deficiencies and inclusion of physician nutrition specialists, dietitians, and other nutrition care specialists in patient care.
Keywords: Dietitian, Glucagon-like peptide-1 receptor agonists, Nutritional deficiency, Obesity, Overweight, Type 2 diabetes
Graphical abstract
Highlights
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This study examines nutritional risks in adults who undergo GLP-1RA treatment, including those with type 2 diabetes, prediabetes, and other conditions for which GLP-1RAs may be prescribed.
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The question of key interest was ‘Do adults undergoing GLP-1RA treatment experience a greater risk of nutritional deficiencies?’.
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We found that adults using GLP-1RAs had a higher incidence of nutritional deficiencies based on ICD-10 coding at 6- and 12-month intervals.
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Our findings indicate healthcare providers prescribing GLP-1RAs should monitor patients for nutritional deficiencies.
Twitter Summary: An analysis of claims data for over 400,000 GLP-1RA users with no history of nutrition deficiency finds that over 20 % had a diagnosed nutritional deficiency within one year.
1. Introduction
Type 2 diabetes (T2D) and obesity are highly prevalent in countries worldwide. Globally more than half a billion people have diabetes (>6 %), while 38 million US adults (∼11 %) have diabetes [1,2]. At the same time, worldwide rates of overweight and obesity continue to increase for reasons that may include economic growth and industrialization, sedentary lifestyles, limited access to physical activity, and transitions to processed foods and high-calorie diets [3]. Worldwide, the prevalence of overweight and obesity is predicted to increase from 38 % of the global population in 2020 to over 50 % by 2035 [4]. Clinicians and researchers recognize that T2D and obesity are interrelated conditions associated with adverse health consequences such as metabolic impairments, cardiovascular dysfunction, physical disability, sarcopenia, declining quality of life, and decreased survival [[5], [6], [7], [8], [9]].
There are a variety of treatment options to consider in obesity care—medical nutrition therapy, physical activity, stress reduction, pharmacotherapy, and bariatric surgical procedures. Although these strategies are often used in combination, nutritional management involving a registered dietitian nutritionist (RDN), along with an individualized reduced-calorie diet are crucial for effective weight reduction and maintenance [10].
The importance of the dietitian’s role in obesity care is underlined by their ability to evaluate, diagnose, and counsel on nutritional status and micronutrient deficiencies (e.g. calcium, magnesium, and vitamins A, C, D, and E) prior to, during, and after reduced caloric diet or obesity medication [11]. In addition, physical activity in combination with pharmacotherapy leads to greater weight reduction and can help preserve muscle mass [12]. The pharmacotherapeutic agents known as glucagon-like peptide receptor agonists (GLP-1RAs) have been available for nearly two decades and have demonstrated both glycemic and weight-reduction benefits for people with T2D, obesity, or both [13,14].
Although GLP-1RAs are thought to inhibit glucagon release and stimulate insulin secretion while interacting with appetite-regulating centers in the hindbrain, hypothalamus, and mesolimbic pathway, the precise mechanisms of this class of drugs remain incompletely understood [[15], [16], [17]]. GLP-1RA actions are associated with appetite reduction [18], heightened satiety [19], and decreased food cravings [[20], [21], [22], [23]].
However, these benefits are not without costs. With the marked reduction in overall food intake with GLP-1RAs, it is important for both clinicians and researchers to examine how the use of these medications affects the quality and adequacy of macronutrient and micronutrient intake [24]. Individuals with obesity are already at risk for micronutrient deficiencies due to poor diet quality and chronic inflammation. GLP-1RA-induced reductions in food intake may further reduce intake of essential nutrients. Vitamin D deficiency, in particular, is common due to sequestration in adipose tissue and limited sun exposure, and may worsen with weight loss unless adequately supplemented [25,26].
Obesity and malnutrition can coexist, and malnutrition may be underdiagnosed or misunderstood in individuals with overweight or obesity, especially in general medical and primary care settings. Malnutrition is also common among older adults; over 5 % of US Medicare beneficiaries (65 years and older) had diagnosed malnutrition, which was associated with a 69 % increase in risk of death and significantly greater annual healthcare costs compared to well-nourished counterparts, underscoring the importance of timely nutrition screening and intervention as needed [27].
This cohort study used a large sample of people with overweight or obesity (body mass index (BMI) 25–29.9 kg/m2 or BMI>30 kg/m2, respectively), often with type 2 diabetes, who were being treated with GLP-1RA. The goal was to determine whether the presumed reduction in dietary intake was associated with subsequent micronutrient deficiencies (vitamins and minerals) [28]. A secondary objective was to compare the incidence of deficiencies between patients prescribed GLP-1RAs and a propensity-matched cohort of patients prescribed metformin only.
2. Methods
2.1. Data source
This observational, real-world data retrospective analysis included individuals with healthcare claims between January 1, 2017 and December 31, 2022 in the Inovalon Insights Claims Data (Inovalon, Maryland, US). Individuals were included if they were adults (aged 18–89 years), newly prescribed a GLP-1RA drug (between July 1, 2017, and December 31, 2021), and if they had 6 months continuous health insurance enrollment prior to GLP-1RA prescription initiation (pre-index interval; GLP-1RA prescription as the index event) and 12 months continuous enrollment following the GLP-1RA prescription (post-index interval). GLP-1RA initiation was defined based on the prescription fill date recorded in the claims database. Individuals were excluded if they had a diagnosed nutritional deficiency within 6 months before the first GLP-1RA prescription (prevalent nutritional deficiency). Of the total 109,006,446 individuals, we identified 461,382 who met the inclusion/exclusion criteria. No identifiable private information was available to the authors or used in this analysis, so no ethics committee approval was required.
2.2. Study design, endpoints, and comparative analyses
Diagnosed nutritional deficiencies were identified using the International Classification of Diseases (ICD)-10 diagnosis codes and were limited to micronutrient deficiencies (e.g., vitamin B12, iron, zinc); macronutrient deficiencies were not assessed. The dataset did not include details on the method of assessment or clinical context for these diagnoses. These codes included protein-calorie malnutrition, specific vitamin and mineral deficiencies, dehydration, and complications related to nutritional-deficiencies (nutritional anemias, coagulation factor deficiency, muscle loss). As with nutritional deficiencies, muscle loss was identified based on diagnosis codes, and the specific method of clinical assessment was not available. These diagnoses were derived from claims submitted by medical providers (generalists or specialists) and were not limited to acute or chronic conditions. Although the majority of the study population had type 2 diabetes (T2DM), the cohort also included individuals with type 1 diabetes, prediabetes, or no recorded diabetes diagnosis at baseline.
Primary endpoints of incidence of nutritional deficiencies and complications of nutritional deficiencies (in specific nutrient categories or in specific nutrition-related consequences) were calculated as the share of eligible individuals with a new diagnosis of nutritional deficiency within 180 days (6 months) and 365 days (12 months) of GLP-1RA initiation. Between-group differences in the incidence of nutritional deficiencies or complications were tested using a Chi-squared test. A two-sided alpha of 0.05 was used to determine significance.
For insights into nutritional care received by GLP-1RA users, patients were grouped by whether they had dietitian visits recorded within the interval of 6 months after starting GLP-1RA therapy. Incidence of nutritional deficiencies or deficiency-related complications were compared between the group with dietitian visits versus the group without dietitian visits as secondary endpoints. The rationale for this analysis strategy was that, although claims data do not code categories of nutritional care (dietary suggestions, nutritional counseling, and use of oral nutritional supplement), such data do include coded/recorded dietitian visits, and so dietitian visits were an indicator of nutrition care that was observable in this data. However, the dataset does not include information on the type, duration, or specific content of care provided during the dietitian visits, and therefore, the analysis was limited to visit presence only. Between-group differences were tested using a Chi-squared test.
Propensity matching was used to build a cohort that controlled for potential differences due to confounders and selection biases between GLP-1RA users and non-users [29]. For this analysis, the sample included patients with T2D who were managed with metformin for glucose control, with or without concomitant GLP-1RA use. The longitudinal aspect of the data allowed for determining when GLP-1RA was added to the patient’s glucose-control regimen. GLP-1RA users and non-users were matched using monthly hazard estimates based on patient age, sex, race, healthcare costs at baseline, and comorbidities using time-dependent Cox proportional hazard model, with exact matching months of metformin use and cohort year. Non-users were defined as individuals who were prescribed metformin only and did not receive any GLP-1RA prescriptions during the observation period. Both the GLP-1RA and comparator groups included patients whose first diabetes medication was metformin. Matching also accounted for the use of other diabetes drugs at the index date. This approach ensured that both groups had a similar course of care for diabetes management and enhanced comparability. Incidence of diagnosed nutritional deficiencies was then compared across the matched patient cohorts using Chi-squared tests. Statistical analysis was conducted using RStudio 2022.07.1 + 554 and R4.2.1.
3. Results
In this claims data cohort (n = 461,382) followed between January 2017 and December 2022, the most prescribed GLP-1RA drugs were dulaglutide (38.4 %), semaglutide (28.8 %), and liraglutide (28.4 %). The relative use of the drugs shifted over time, with dulaglutide and liraglutide used commonly in 2017–2018, while semaglutide was the most prescribed drug in 2021.
Demographics and general health of included individuals at baseline are reported in Table 1. Individuals with GLP-1RA prescriptions were of mean age 53 years old, mostly female (56 %), had type 2 diabetes (80.5), hypertension (66.3 %) and obesity (44.9 %). Nearly 92 % of patients in the cohort had not visited a dietitian 6 months prior to GLP-1RA prescription. Among GLP-1RA users, 8.3 % had a dietitian visit within the 180 days prior to treatment initiation.
Table 1.
Baseline characteristics of adult patients (n = 361,382).
| Characteristic | N (%) |
|---|---|
| Age | |
| Mean (SD) | 52.9 (11.7) |
| Sex | |
| Male | 201523 (43.7) |
| Female | 259852 (56.3) |
| Race | |
| Asian | 11565 (2.5) |
| Black | 44666 (9.7) |
| Hispanic | 55341 (12) |
| White | 144852 (31.4) |
| Other | 24088 (5.2) |
| Unknown | 180870 (39.2) |
| Diabetes status | |
| Type 1 diabetes | 16710 (3.6) |
| Type 2 diabetes | 371183 (80.5) |
| Prediabetes | 9384 (2) |
| No diabetes diagnosis/unknown | 64105 (13.9) |
| Dietitian (within 180 days prior to GLP-1RA initiation, %) | |
| Yes | 38484 (8.3) |
| No | 422898 (91.7) |
| Comorbidities | |
| Hypertension | 305703 (66.3) |
| Chronic Kidney Disease | 25532 (5.5) |
| Non-alcoholic Fatty Liver Disease | 27592 (6) |
| Obesity | 206940 (44.9) |
| Overweight | 26004 (5.6) |
Abbreviations: SD, standard deviation.
∗Dietitian visit refers to visit to a dietitian within 0–180 days prior to data index date.
Comorbidities were assessed 0–180 days prior to data index date.
Obesity and overweight were included as comorbidities due to their relevance to nutritional status and risk of muscle loss. Other listed characteristics such as hypertension, CKD, and NAFLD are included as descriptive clinical characteristics to contextualize patient health status. Table 2 reports the incidence of nutritional deficiencies and nutritional complications in the GLP-1RA-treated population. Nearly 13 % of GLP-1RA patients had some type of nutritional deficiency within 6 months of starting GLP-1RA therapy; 22 % within 12 months of starting GLP-1RA therapy. The most common nutritional deficiency was vitamin D deficiency (7.5 % after 6 months, 13.6 % after 12 months). The most common deficiency-related complication was nutritional anemia (2.1 % after 6 months, 4 % after one year). It is also notable that 3 % of patients were diagnosed with muscle loss within a year of starting GLP-1RA therapy.
Table 2.
Incidence of nutritional deficiencies and deficiency-related complications in GLP-1RA-treated adults at 6 and 12 months (n = 461,382).
| Deficiency or deficiency complication | 6 months |
12 months |
|---|---|---|
| N (%) | N (%) | |
| Any nutrition deficiency or deficiency complication | 58455 (12.7) | 103366 (22.4) |
| Composite nutritional deficiencies | 47568 (10.3) | 85495 (18.5) |
| Protein-calorie malnutrition (E4[3,5,6], E44.[0,1], E4[0–2]) | 1155 (0.3) | 2628 (0.6) |
| Vitamin deficiency | 38346 (8.3) | 69510 (15.1) |
| Vitamin A deficiency (E50.[0–9]) | 80 (0) | 193 (0) |
| Thiamine deficiency (E51.1[1,2], E51.[2,8,9]) | 96 (0) | 245 (0.1) |
| Niacin deficiency (E52) | 3 (0) | 4 (0) |
| Other vitamin B deficiency (E53.[0,1,8,9]) | 6118 (1.3) | 12151 (2.6) |
| Vitamin C deficiency (E54) | 23 (0) | 55 (0) |
| Vitamin D deficiency (E55.9) | 34658 (7.5) | 62864 (13.6) |
| Other vitamin deficiency (E56.[0,1,8,9]) | 881 (0.2) | 1870 (0.4) |
| Mineral deficiency | 1755 (0.4) | 3626 (0.8) |
| Calcium deficiency (E58) | 39 (0) | 65 (0) |
| Selenium deficiency (E59) | 13 (0) | 23 (0) |
| Zinc deficiency (E60) | 54 (0) | 102 (0) |
| Other mineral deficiency (E61.[0–6]) | 1661 (0.4) | 3468 (0.8) |
| Volume depletion (dehydration) (E86.[0,1,9]) | 8469 (1.8) | 16163 (3.5) |
| Other nutritional deficiency (E61.[7–9], E63.[0,1,8,9]) | 395 (0.1) | 807 (0.2) |
| Composite nutritional deficiency with complications | 16026 (3.5) | 30910 (6.7) |
| Acquired coagulation factor deficiency (D68.4) | 51 (0) | 130 (0) |
| Nutritional anemia | 9540 (2.1) | 18554 (4) |
| Iron deficiency anemia (D50.[1,8,9]) | 7452 (1.6) | 14593 (3.2) |
| Other nutritional anemia (D51.[3,8,9], D52.[0,8,9], D53.[0–2,8,9]) | 2509 (0.5) | 5009 (1.1) |
| Muscle loss (M62.84, R64, E88.A, M62.5[0,8,9], M62.5[1–7,A][1,2,9], M62.5A0, M62.81, M62.82) | 6891 (1.5) | 13661 (3) |
Abbreviations: GLP-1RA, glucagon-like peptide-1 receptor agonists.
All primary endpoints were assessed at 180 days and 365 days post-index for cumulative incidence.
Table 3 presents the comparative analysis of nutrition deficiency incidences in matched cohorts of adults with T2D treated with GLP-1RA plus metformin versus those treated with metformin only. Time-dependent matching of GLP-1RA users and non-users resulted in 4505 patients matched from each cohort. Except for other vitamin B deficiency (p < 0.01), no other statistically significant differences in incidences were observed at 6 months after index date. However, in addition to other vitamin B deficiency, overall incidences of nutrition deficiencies were higher for GLP-1RA users at 12 months after index date, in particular thiamine and vitamin D.
Table 3.
Comparison of incidence of nutrition deficiencies at 6 and 12 months after index date of cohorts of GLP-1RA and metformin users and and matched non-users prescribed metformin-only.
| 6 months |
12 months |
|||
|---|---|---|---|---|
| Control (N = 4505) |
GLP-1RA (N = 4505) |
Control (N = 4505) |
GLP-1RA (N = 4505) |
|
| N (%) | N (%) | N (%) | N (%) | |
| Any nutrition deficiency or deficiency complication | 413 (9.2) | 466 (10.3) | 743 (16.5) | 839 (18.6)∗∗ |
| Composite nutritional deficiencies | 315 (7.0) | 364 (8.1) | 590 (13.1) | 679 (15.1)∗∗ |
| Protein-calorie malnutrition | 7 (0.2) | 13 (0.3) | 15 (0.3) | 27 (0.6) |
| Vitamin deficiency | 247 (5.5) | 290 (6.4) | 464 (10.3) | 551 (12.2)∗∗ |
| Vitamin A deficiency | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Thiamine deficiency | 0 (0) | 5 (0.1) | 0 (0) | 7 (0.2)∗∗ |
| Niacin deficiency | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Other vitamin B deficiency | 26 (0.6) | 50 (1.1)∗ | 61 (1.4) | 105 (2.3)∗∗ |
| Vitamin C deficiency | 0 (0) | 0 (0) | 0 (0) | 1 (0) |
| Vitamin D deficiency | 225 (5.0) | 259 (5.7) | 416 (9.2) | 489 (10.9)∗∗ |
| Other vitamin deficiency | 8 (0.2) | 12 (0.3) | 16 (0.4) | 17 (0.4) |
| Mineral deficiency | 12 (0.3) | 17 (0.4) | 25 (0.6) | 35 (0.8) |
| Calcium deficiency | 0 (0) | 0 (0) | 0 (0) | 1 (0) |
| Selenium deficiency | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Zinc deficiency | 0 (0) | 1 (0) | 1 (0) | 1 (0) |
| Other mineral deficiency | 12 (0.3) | 16 (0.4) | 24 (0.5) | 33 (0.7) |
| Volume depletion | 59 (1.3) | 70 (1.6) | 112 (2.5) | 124 (2.8) |
| Other nutritional deficiency | 4 (0.1) | 4 (0.1) | 5 (0.1) | 6 (0.1) |
| Composite nutritional deficiency complications | 134 (3.0) | 145 (3.2) | 239 (5.3) | 267 (5.9) |
| Acquired coagulation factor deficiency | 1 (0) | 1 (0) | 3 (0.1) | 4 (0.1) |
| Nutritional anemia | 90 (2.0) | 81 (1.8) | 164 (3.6) | 158 (3.5) |
| Iron deficiency anemia | 69 (1.5) | 65 (1.4) | 134 (3.0) | 127 (2.8) |
| Other nutritional anemia | 27 (0.6) | 19 (0.4) | 40 (0.9) | 36 (0.8) |
| Muscle loss | 48 (1.1) | 65 (1.4) | 91 (2.0) | 111 (2.5) |
Abbreviations: GLP-1RA, glucagon-like peptide-1 receptor agonists.
∗ - p < 0.05; ∗∗ - p < 0.01.
Table 4 reports the number and percentage of patients with recorded nutritional deficiencies; patients are grouped according to whether a dietitian was consulted within 6 months of starting GLP-1RA therapy. Identification of any nutritional deficiency was significantly more likely for those who saw a dietitian (1.4–1.5-times), as measured at 6 months (18.5 % versus 12.2 %, p < 0.01) and 12 months (29.8 % versus 21.8 %, p < 0.01) after starting therapy.
Table 4.
Incidence of nutrition or micronutrient deficiency at 6 and 12 months after GLP-1RA initiation in adults with/without a dietitian visit at 6 months.
| 6 months |
12 months |
|||
|---|---|---|---|---|
| With dietitian visit (N = 36,802) | No dietitian visit (N = 424,580) | With dietitian visit (N = 36,802) | No dietitian visit (N = 424,580) | |
| Any nutrition deficiency or deficiency complication | 6797 (18. 5) | 51658 (12.2) ∗∗ | 10983 (29.8) | 92383 (21.8) ∗∗ |
| Composite nutritional deficiencies | 5743 (15.6) | 41825 (9.9) ∗∗ | 9338 (25.4) | 76157 (17.9) ∗∗ |
| Protein-calorie malnutrition | 195 (0.5) | 960 (0.2) ∗∗ | 382 (1) | 2246 (0.5) ∗∗ |
| Vitamin deficiency | 4728 (12.8) | 33618 (7.9)∗∗ | 7705 (20.9) | 61805 (14.6) ∗∗ |
| Vitamin A deficiency | 19 (0.1) | 61 (0)∗∗ | 39 (0.1) | 154 (0)∗∗ |
| Thiamine deficiency | 35 (0.1) | 61 (0)∗∗ | 75 (0.2) | 170 (0)∗∗ |
| Niacin deficiency | 0 (0) | 3 (0) | 0 (0) | 4 (0) |
| Other vitamin B deficiency | 710 (1.9) | 5408 (1.3) ∗∗ | 1338 (3.6) | 10813 (2.5) ∗∗ |
| Vitamin C deficiency | 4 (0) | 19 (0) | 7 (0) | 48 (0) |
| Vitamin D deficiency | 4321 (11.7) | 30337 (7.1) ∗∗ | 7006 (19) | 55858 (13.2) ∗∗ |
| Other vitamin deficiency | 166 (0.5) | 715 (0.2) ∗∗ | 335 (0.9) | 1535 (0.4) ∗∗ |
| Mineral deficiency | 266 (0.7) | 1489 (0.4) ∗∗ | 512 (1.4) | 3130 (0.7) ∗∗ |
| Calcium deficiency | 7 (0) | 32 (0)∗∗ | 13 (0) | 54 (0)∗∗ |
| Selenium deficiency | 2 (0) | 11 (0) | 6 (0) | 17 (0)∗∗ |
| Zinc deficiency | 11 (0) | 43 (0)∗∗ | 25 (0.1) | 77 (0)∗∗ |
| Other mineral deficiency | 249 (0.7) | 1412 (0.3)∗∗ | 475 (1.3) | 2993 (0.7)∗∗ |
| Volume depletion (dehydration) | 875 (2.4) | 7594 (1.8) ∗∗ | 1654 (4.5) | 14509 (3.4) ∗∗ |
| Other nutritional deficiency | 104 (0.3) | 291 (0.1) ∗∗ | 183 (0.5) | 624 (0.1) ∗∗ |
| Composite nutritional deficiency complications | 1799 (4.9) | 14227 (3.4) ∗∗ | 3276 (8.9) | 27634 (6.5) ∗∗ |
| Acquired coagulation factor deficiency | 4 (0) | 47 (0) | 16 (0) | 114 (0) |
| Nutritional anemia | 1135 (3.1) | 8405 (2) ∗∗ | 2067 (5.6) | 16487 (3.9) ∗∗ |
| Iron deficiency anemia | 844 (2.3) | 6608 (1.6) ∗∗ | 1595 (4.3) | 12998 (3.1) ∗∗ |
| Other nutritional anemia | 360 (1) | 2150 (0.5) ∗∗ | 618 (1.7) | 4391 (1) ∗∗ |
| Muscle loss | 713 (1.9) | 6178 (1.5) ∗∗ | 1360 (3.7) | 12301 (2.9) ∗∗ |
Abbreviations: GLP-1RA, glucagon-like peptide-1 receptor agonists.
All primary endpoints were assessed at 180 days and 365 days post-index for cumulative incidence with 95 % confidence interval using Chi-square test. ∗ - p < 0.05; ∗∗ - p < 0.01.
Among patients prescribed GLP-1RA, the average time for a dietitian visit was 128.5 days after the start of GLP-1RA therapy, i.e. about 4 months.
4. Discussion
4.1. Summary of key findings and interpretation
This analysis quantified nutritional deficiencies among a large cohort of US adults prescribed GLP-1RA between 2017 and 2022, in which more than half had obesity or overweight and more than 80 % had type 2 diabetes. The analysis found that after GLP-1RA initiation, nearly 13 % of those in the cohort were diagnosed with nutritional deficiencies after 6 months and over 22 % after 12 months. Vitamin D deficiency was the most frequently diagnosed subtype (6-month incidence was 7.5 %; 12-month incidence was 13.6 %). In addition, nutrient deficiencies or deficiency-related complications were significantly more likely to be recorded for patients who had a dietitian visit within 6 months of GLP-1RA initiation. Among patients who visited a dietitian, approximately one in three had a nutritional deficiency diagnosis, one in five had vitamin D deficiency, 6 % had nutritional anemia, and 4 % had muscle loss 12 months after GLP-1RA initiation.
These associations may reflect greater clinical complexity or nutritional risk among patients referred to dietitians, and greater opportunity for deficiency detection. Across each individual nutrient or deficiency-related complication evaluated, higher rates of diagnoses were observed among patients who had a dietitian visit, although this may be related to greater screening opportunities or underlying comorbidity burden rather than the visit itself. Patients who had dietitian visits were more likely to have obesity and a history of prior dietitian care, which may indicate greater underlying nutritional risk. The higher incidence of deficiency diagnoses in this group may reflect both increased clinical complexity and increased opportunity for detection, rather than a detrimental effect of dietitian care itself. However, these observational findings do not allow for causal interpretation. While causality or optimal referral timing cannot be determined from this observational analysis, the findings underscore the importance of considering multidisciplinary care models that include dietitians and other nutrition professionals, in monitoring and addressing nutrition deficiencies, although this study does not confirm the involvement or impact of such providers.
4.2. Health concerns accompanying weight loss mediated by GLP-1RAs
Adults with severe obesity are already at risk of micronutrient deficiency, and marked reduction in overall dietary intake while taking obesity medications can also contribute to micronutrient shortfalls [25,30]. Deficiency of key micronutrients like vitamin D, B12, folic acid, copper, and zinc is detected among people with obesity. Micronutrient deficiencies could be attributed to poor diet quality with decreased intake of vitamins and minerals or due to altered microbiome among people with obesity [26].
Loss of muscle mass is another concern when treating obesity. This risk requires close monitoring and assessment over the course of GLP-1RA use [31]. A study evaluating the effects of semaglutide and tirzepatide on energy intake and body composition, demonstrated weight loss is predominantly driven by fat mass loss, but a small portion (1.4 %, 2.6 % respectively) due to loss of fat-free mass, primarily muscle [25,30,32]. A study by Heymsfield et al. demonstrated that in the absence of a structured exercise program, 20–25 % of the weight lost from caloric restriction in males and 10–15 % in females, was skeletal muscle [28].
Recent findings suggest that GLP-1RA-induced weight loss may reduce lean body mass by as much as 20–50 % in some individuals, particularly without concurrent lifestyle interventions [33,34]. However, structured intensive lifestyle intervention (sILI) with adequate protein intake and resistance exercise may mitigate muscle loss, as demonstrated in trials of patients on GLP-1RAs who maintained fat-free mass [35]. Improvements in muscle quality and insulin sensitivity may offset reductions in muscle mass, though further human studies are needed [36].
Incorporating exercise during treatment appears to mitigate this loss. One study found that weight loss was maintained one year after treatment only when a supervised exercise component was added to pharmacotherapy, compared with pharmacotherapy alone [37]. Strength and resistance exercise has been advised [38], as has a combination of resistance and endurance exercise [30]. In addition, higher protein intake (1.2–1.5 g/kg/day) is recommended for healthy adults >65 years and for patients after bariatric surgery to protect muscle. The optimal amount during GLP-1RA treatment is not known; thus, protein intake should be adapted to individual needs [31]. In preclinical models, semaglutide was shown to impair growth and thermogenesis in protein-malnourished juvenile mice, highlighting the importance of adequate protein intake in vulnerable populations [39].
The appetite-suppressing effect of GLP-1RAs contributes to reduced energy intake, with studies reporting reductions of up to 39 % [40]. While beneficial for weight loss, this may lead to decreased intake of essential nutrients. Gastrointestinal side effects—such as nausea, vomiting, and delayed gastric emptying—can further impact food variety and nutrient absorption [41,42]. GLP-1RA-induced delayed gastric emptying and gut microbiota modulation may alter micronutrient metabolism and absorption, though direct evidence of clinically significant deficiencies is limited [43].
A potential concern is the suppression of thirst (hypodipsia), which has been observed in users of certain GLP-1RAs and may increase the risk of dehydration, particularly in older adults [44]. Close monitoring of hydration status is therefore recommended, especially during initial titration or dose escalation. Monitoring for nutritional risks, including vitamin B12 deficiency, has been recommended. Notably, semaglutide may interfere with B12 assay results, potentially leading to false low levels when used alongside metformin [45]. Laboratory tests (e.g., vitamin B12, 25(OH) vitamin D, iron, folic acid) can be ordered to screen for micronutrient insufficiency [46].
Dietary counseling by a physician nutrition specialist, RDN, or other trained clinician may support better nutritional monitoring and outcomes in patients with obesity/overweight and/or type 2 diabetes. The Academy of Nutrition and Dietetics calls on the medical community “to maximize patient success rates by including a referral for medical nutrition therapy from a registered dietitian nutritionist,” a recommendation that is particularly relevant for patients managed with obesity medications [47]. Although nutrition monitoring is supported by the 2025 ADA Standards of Care for people with diabetes [48], no universally accepted guidelines currently exist regarding nutrition screening and monitoring in obesity pharmacotherapy. The Obesity Medicine Association (OMA) [49] emphasizes the importance of individualized nutrition care in clinical practice statements, but standardized recommendations remain limited.
Treating obesity requires tailoring nutrition therapy to the individuals. Despite decades of studies, no single diet has emerged as the most effective nutrition treatment. Therefore, it is important to include education and guidance by a dietitian or other nutrition specialist. New long-acting GLP-1 RA agents are highly effective for glycemic control, obesity treatment, and reducing cardiometabolic and kidney risk [21,50,51]. As these medications develop, nutrition strategies will gain importance in multidisciplinary care.
5. Limitations
Strengths of the current analysis include documentation of specific nutritional deficiencies and nutrition-related complications in large cohort (more than 400,000 healthcare claims records) of patients with diabetes prescribed GLP-1RAs, including the highly effective semaglutide approved for use in diabetes or more recently approved GLP-1RAs for chronic weight management. This study also uses advanced statistical methods to match patients who were GLP-1RA users with non-users in a way that reduced confounding.
A key limitation of this analysis is its use of claims data, which relied on the clinician to identify, document, and bill for the diagnoses, services, and outcomes captured. As such, it does not reflect recommendations, education, or other health or community resources available to practitioners or patients, nor does it reflect the acceptance, execution, or impact these interventions may have on patient nutrition outcomes. Additionally, the primary analysis did not include a control group of non–GLP-1RA users, and as such, incidence of nutritional deficiencies in this cohort cannot be directly compared to background rates in the general population or among non-users. Further, although most individuals in the study cohort had type 2 diabetes, the population also included individuals with overweight or obesity and other metabolic conditions; therefore, the findings may not be specific to individuals with diabetes alone. Finally, this analysis relied on observational data and was therefore not able to establish a causal link between dietitian visits and the diagnosis of nutritional deficiency. While existing deficiencies are more likely to be identified in patients who see a dietitian, it is also more likely that patients with existing deficiencies will be referred to a dietitian. In general, nutritional deficiencies and nutritional risks are often under-diagnosed, especially in those with obesity. In addition, visits to registered dietitian nutritionists (RDNs) that were paid out-of-pocket or not submitted for insurance reimbursement are not captured in this dataset. Therefore, it is possible that some nutrition care encounters were missed, potentially leading to underestimation of dietitian involvement. The analysis likely captures just the minimum levels of nutritional deficiencies.
Further, the dataset does not capture use of over-the-counter or prescription dietary supplements, and individuals frequently underreport supplement use. As such, we were unable to assess the impact of supplementation (e.g., vitamin D, iron, or multivitamins) on observed nutrient deficiencies. Information on participation in structured physical activity, exercise frequency, or involvement with medical fitness professionals was also unavailable, which may limit interpretation of observed muscle loss outcomes.
6. Conclusion
In a large cohort of adults with obesity/overweight and/or type 2 diabetes, over 20 % had nutritional deficiencies diagnosed within 12 months of GLP-1RA initiation.
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•
Since nutritional deficiencies are often underdiagnosed [52], these findings, along with loss of muscle mass reported from earlier drug trials [28], highlight the need for nutrition specialists in identifying, correcting and managing deficiencies in this population, though the data do not establish the optimal timing or clinical impact of referral.
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•
We anticipate that timely use of nutritional therapy with fiber-rich, adequate protein and micronutrient content may help optimize nutritional status, mitigate loss of muscle mass, and improve overall health. However, further research is needed to establish effectiveness.
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•
Future studies are needed to develop and validate specific and clear guidelines for monitoring and managing the nutritional status of patients on GLP-1RAs.
Author contributions
A.T.C, J.A.K., T.P, S.G. conducted data analysis, interpreted data analysis, contributed to discussion and reviewed and edited the manuscript. S.S. K.W.K, D.R.W, R.H, W.S.B, and S.B.H reviewed and interpreted data analysis, contributed to discussion, and edited the manuscript. All authors approved the final version of the manuscript.
Data availability
The data that support the findings of this study are available from Inovalon but restrictions apply to the availability of these data, which were used under license for the current study and therefore are not publicly available. Data are however available from the authors upon reasonable request and with permission of Inovalon.
Guarantor
Scott Goates is the guarantors of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Prior presentation
An abstract containing a portion of this work was previously presented at ObesityWeek, November 3–6, 2024, San Antonio, TX, USA.
Declaration of artificial intelligence (AI) and AI-assisted technologies
Artificial intelligence (AI) and AI-assisted technologies were not utilized in the writing process.
Funding
This study financially supported by Abbott.
Declaration of competing interest
S Sulo, AT Chang, JA Kim, KW Kerr, DR Williams, R Hegazi, T Panchalingam, and S Goates are employees of Abbott. S Butsch and S Heymsfield performed work on this study under contract with Abbott.
Acknowledgements
The authors thank Cecilia Hofmann, PhD for manuscript drafting and editing, and Bhavadharini Balaji, PhD for support with manuscript drafting, revisions, and literature synthesis.
Contributor Information
W. Scott Butsch, Email: butsch2@ccf.org.
Suela Sulo, Email: suela.sulo@abbott.com.
Andrew T. Chang, Email: Andrew.chang2@abbott.com.
Jeeyun A. Kim, Email: Jeeyun.kim@abbott.com.
Kirk W. Kerr, Email: kirk.kerr@abbott.com.
Dominique R. Williams, Email: Dominique.williams1@abbott.com.
Refaat Hegazi, Email: Refaat.hegazi@abbott.com.
Thadchaigeni Panchalingam, Email: Thadcha.panchalingam@abbott.com.
Scott Goates, Email: Scott.goates@abbott.com.
Steven B. Heymsfield, Email: Steven.Heymsfield@pbrc.edu.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from Inovalon but restrictions apply to the availability of these data, which were used under license for the current study and therefore are not publicly available. Data are however available from the authors upon reasonable request and with permission of Inovalon.