Is lifestyle counseling necessary when using more effective second-generation trophotropic hormone-based drugs such as semaglutide and tirzepatide?
If so, how intensive should the counseling be and what elements should it emphasize?
These are the top questions in clinical practice for healthcare professionals and researchers who provide care for overweight and obese patients.
Here's what we know. Lifestyle management is considered the cornerstone of care for obese patients.
Because obesity is fundamentally a disease of energy dysregulation, counseling has traditionally focused on strategies to reduce dietary calories, increase physical activity, and adapt new cognitive and lifestyle behaviors.
Based on trial results from the Diabetes Prevention Program and the Look AHEAD study, the Centers for Medicare and Medicaid Services and the U.S. Task Force on Preventive Services (Moyer VA) recommend providing intensive behavioral therapy (IBT) for the treatment of obesity. ; U.S. Preventive Services Task Force).
IBT is generally defined as consisting of 12 to 26 comprehensive multicomponent sessions over a one-year period.
Reaffirming the importance of lifestyle management, all anti-obesity drugs are approved by the U.S. Food and Drug Administration as adjuncts to reduced-calorie diets and increased physical activity.
The beneficial effects of combining IBT with older generation drugs such as naltrexone/bupropion and liraglutide mean that more study participants lost 10% or more of their body weight with IBT compared to subjects who took the drug without IBT. We demonstrated that we achieved a reduction of: 38.4% vs. 20% for naltrexone/bupropion and 46% vs. 33% for liraglutide.
Although there is no trial data for other first-generation drugs such as phentermine, orlistat, and phentermine/topiramate, it is assumed that patients taking these drugs will achieve greater weight loss when combined with IBT. I am.
However, the approval of the glucagon-like peptide-1 (GLP-1) receptor agonist semaglutide (Wegovy) in 2021 changed the landscape of obesity drug therapy. and tirzepatide (Zepbound), a dual receptor agonist for GLP-1 and glucose-dependent insulinotropic polypeptide (GIP), will be launched in 2023.
These highly effective drugs harness the effects of naturally occurring incretin hormones, which reduce appetite through direct and indirect effects on the brain. Although the STEP 1 and STEP 3 trials had different study designs, adding his IBT to semaglutide increased mean weight loss from 15% to 16% after 68 weeks of treatment (Wilding JPH et al; Wadden TA).
Comparable benefits from the STEP 3 and SURMOUNT-1 trials that added IBT to tirzepatide at the maximum tolerated dose increased mean weight loss from 21% to 24% after 72 weeks (Wadden TA; Jastreboff AM) . Multicomponent IBT appears to produce greater weight loss when combined with trophotropic hormone-based treatments, but the additional benefits may be small compared to first-generation drugs.
So how should we view the role and importance of lifestyle management when patients are taking second-generation drugs? The focus needs to shift to counseling for the pattern.
Second-generation drugs have a greater biological effect on suppressing appetite (i.e., they reduce hunger, food noise, and cravings, and increase feelings of fullness and fullness), so patients feel a sense of deprivation. It makes it easier to reduce food intake without having to eat. Additionally, many patients have a low desire to eat savory, sweet, and other appealing foods.
Patients should be encouraged to optimize diet quality by prioritizing lean protein sources at meals and snacks. Increase fruits, vegetables, fiber, and complex carbohydrates. And be sure to stay hydrated. Because of the risk of developing micronutrient deficiencies (particularly calcium, iron, and vitamin D) while on a low-calorie diet, patients may be advised to take a daily multivitamin supplement. Dietary counseling should be introduced when patients begin drug therapy, and if necessary, referral to a registered dietitian may be helpful in making these changes.
Additional counseling tips to reduce gastrointestinal side effects of these drugs, which most commonly occur during the early stages of dose titration, include eating slowly. Choose smaller portions. Stop eating when you are full. Don't skip meals. And avoid fatty, fried, and greasy foods. These dietary changes are especially important during the first few days after a patient receives the injection.
The increased weight loss achieved also raises concerns about the need to maintain lean body mass and the importance of physical activity and exercise counseling. All weight loss interventions, including dietary restriction, pharmacotherapy, and bariatric surgery, result in a decrease in fat mass and lean body mass.
The goal of lifestyle counseling is to minimize and maintain muscle mass (a component of lean body mass) necessary for optimal health, mobility, daily function, and quality of life. Counseling should incorporate both aerobic and strength training. Aerobic exercise (brisk walking, jogging, dancing, elliptical machine, cycling, etc.) improves cardiovascular health, metabolic health, and energy expenditure. Resistance (strength) training (e.g., weightlifting, resistance bands, circuit training) reduces muscle loss, increases functional strength and mobility, and improves bone density (Gorgojo-Martinez JJ et al; Oppert JM et al).
Steady physical activity has also been shown to be a predictor of weight loss maintenance. A recently published randomized, placebo-controlled trial demonstrated the benefit of supervised exercise compared to no exercise in maintaining body weight and lean body mass after 52 weeks of liraglutide treatment discontinuation. Ta.
How obese patients can strive to achieve healthy, productive lives by using highly effective second-generation treatments rather than minimizing the provision of lifestyle management. will be focused on.
