Recent guidelines from the American College of Cardiology
risk becoming shorthand for the notion that lifestyle does not have primary importance for overall health. The lay press seems to love this angle, publishing headlines stating, "Weight-loss drugs should be first step to prevent heart disease, top cardiology group says."
What's easily lost here is that these new guidelines, written primarily for cardiologists, state that incretins (referred to as nutrient-stimulated hormone therapies or NuSH) should be initiated alongside lifestyle interventions that promote weight loss. The guidelines state: "Comprehensive treatment of obesity is multimodal. Lifestyle interventions support overall weight management, and their utility alongside highly effective obesity medications is evolving." The utility of lifestyle intervention alongside weight-loss medications is actually not "evolving": it is well established that lifestyle interventions support pharmacotherapy and vice versa. Medical society guidelines, consensus statements, and large clinical trials of GLP-1 therapies all include lifestyle counseling as part of the weight management treatment plan.
Even cursory summaries of these guidelines, in both medical literature and the lay press, should highlight the fact that GLP-1 therapy is meant to be initiated alongside lifestyle interventions.
The guidelines also state that individuals should not have to "try and fail" lifestyle interventions before initiating incretin therapy, which opens the door for misinterpretation or dismissal of the role of nutrition and exercise. Attention to lifestyle, specifically a high-quality diet and regular physical activity, has not been and should not be replaced by medications such as semaglutide (Wegovy, Ozempic) and tirzepatide (Zepbound, Mounjaro).
Redefining Failure
The "try and fail" language is flawed when weight loss is used as the primary measure of success with lifestyle interventions. A nutritious diet and regular exercise have been shown to improve blood pressure, blood sugar, insulin sensitivity, muscle and bone strength, balance, and overall mental and physical health.
Dismissing positive changes in diet quality and physical activity unless they produce weight loss is misguided and unnecessarily discouraging for patients with obesity. Saying that a person "failed" lifestyle change because the scale didn't budge very much implies that the person did not try hard enough, which puts us squarely on the road to blaming someone with obesity for their weight. When patients express frustration that exercise and change in diet do not produce "enough" weight loss, medical providers can provide motivation and support by redirecting the lens to other successes and health benefits. The number on the scale is not the only, or even necessarily the most important, readout of a person's overall health.
Here are some real examples of patients who "failed" lifestyle interventions if we use the traditional outcome of weight loss: A construction worker who reduced soda consumption from six cans to one can daily. A young father who joined a "couch to 5K" training program and successfully completed the race. A woman who, after making incremental progress over 4 years, finally swam across Walden Pond. A widow who had been eating lunch and dinner out every day for 3 years learned to prepare healthy, simple meals. A single parent who didn't know that frozen vegetables are perfectly healthy now regularly makes soups and stews loaded with vegetables.
A particularly inspiring woman in her late 70s joined a gym and has worked her way up from 5 minutes on a treadmill or stationary bike to 30 minutes -- and plans to get to 1 hour. She told me, "I never thought I could do these things with my body, and I can't wait to do more. I feel like a totally different person."
None of these patients has had robust weight loss, yet all of them have unquestionably improved their overall metabolic and mental health.
More Research Is Needed on the Specifics of Lifestyle Interventions
Nutrition and exercise counseling are defined and operationalized differently in large clinical studies. Most studies include a reduced-calorie diet and 150 minutes of exercise per week at a minimum, but specific methods, frequency, and duration of counseling can differ significantly by study. These differences make it difficult to tease apart the relative contributions of pharmacotherapy and specific lifestyle interventions to weight loss and improvements in other metabolic parameters. Typically, studies with frequent (weekly or twice monthly) and directly observed interventions are the most successful for weight loss and cardiometabolic measures, verifying the high-touch nature of lifestyle counseling.
While diet content, calorie targets, and timing of meals are highly individualized, guidelines for medical providers would benefit from being more specific than the general "reduced calorie diet" recommendation. Advice about macronutrient intake, ultra processed foods, and sugar-sweetened beverage consumption could be more specific. Similarly, particular examples of moderate and vigorous physical activities are more helpful than targets based on time.
Not least, more research on the timing and escalation of lifestyle intervention in conjunction with pharmacotherapy is needed. One study showed that tirzepatide produced more weight loss when it was started after a run-in phase, where initial weight loss was achieved through nutrition and exercise interventions, compared to starting it alongside lifestyle recommendations.
Pharmacotherapy Is Often Unavailable
As anyone who prescribes GLP-1 therapies is surely aware, access remains a significant barrier to treatment due to lack of insurance coverage and, at times, lack of medication supply. In these millions of cases, lifestyle "failure" is not an option; ongoing guidance about nutrition and exercise are the only options.
Simple, affordable interventions that take into account food insecurity, financial resources, nutrition knowledge, physical limitations, and access to exercise facilities can still result in improved metabolic health, even in the absence of very robust weight loss. No one fails if the bar is set fairly.
No comments:
Post a Comment
Note: Only a member of this blog may post a comment.