Beyond the Scale: Best Practices for Integrating Weight Loss Medications into Your Health Plan

by Rachel DiGiacomo, Registered Dietitian and Founder of Good Sense Nutrition LLC

“What do you think about me starting [insert name of weight loss medication here]?”

I am asked this question on a weekly basis. In the past year, more than half of my clients are now taking weight loss medication. As a weight-inclusive dietitian I advocate for health at every size. I offer support for my clients based on their individual needs. Weight loss is not an exception, however, it is not always the appropriate intervention. In this era of pharmacotherapy, it is important to understand the complexities of utilizing medications like Ozempic, Wegovy, Zepbound and Mounjaro. Medical weight loss can be life changing for the appropriate candidate when coupled with the necessary lifestyle interventions based in nutrition science and behavior change. We must also recognize how these drugs perpetuate fatphobia and weight stigma. The intent of this article is to provide insight on how these drugs can impact eating habits as well as best practices for those choosing to integrate weight loss medication into their care plan. This article is for educational purposes only and is not medical advice. Please consult your physician before starting or stopping any medication. 

How do they work?

Ozempic was originally created to manage Type 2 Diabetes. Semaglutide, the active ingredient, mimics the hormone glucagon-like peptide-1 (GLP-1) receptor agonist. When you eat something, GLP-1 hormone is released to prompt the body to produce insulin, which transports blood sugars to your cells and tissue, thus reducing your blood sugar. When released in higher amounts it will prompt the brain to signal feelings of satiety/fullness by slowing down digestion and reducing appetite. Wegovy has the same active ingredient as Ozempic, but it is prescribed at a higher dose and marketed solely for weight loss. 

Mounjaro, like Ozempic, was created to manage Type 2 Diabetes through a different active ingredient called tirzepatide which targets GLP-1 and glucose-dependent insulinotropic polypeptide (GIP) co-agonists to help regulate blood sugar and promote satiety. Zepbound has the same active ingredient as Mounjaro, but it is marketed for weight loss. Tirzepatide acts on two hormonal pathways in the body as opposed to one like the active ingredient in Ozempic and Wegovy. This has been shown to have a more powerful impact on weight loss than semaglutide. Research has shown average total body weight loss above 20%.

There is currently a shortage for both Ozempic and Wegovy since being approved for weight loss in 2021. Mounjaro and Zepbound are also in high demand and many patients are struggling to get them as well. Intermittent shortages are expected to continue throughout 2024. Recognizing the demand, compounding pharmacies have made their own versions of each active ingredient without prior FDA screening or approval.

Semaglutide is patented by Novo Nordisk meaning they can only produce it.  This leads compounding pharmacies to use salt forms of semaglutide (semaglutide sodium and semaglutide acetate). These salt forms have not been approved by the FDA which presents questions about their safety, quality, and effectiveness. 

Is it possible to maintain weight loss?

Yes, but it’s not likely. After stopping trials, around ~15% of individuals keep most of their weight off. The new data is not great to draw conclusions just yet.  Studies have shown a reduction in heart attack and stroke. Side effects are nearly universal with 93% of patients experiencing nausea, vomiting, constipation and/or diarrhea. These symptoms tend to lessen overtime with continued medication use. With only a few years of research for these specific drugs, long term side effects are unknown. Pancreatitis and thyroid cancer are among potential risks. It is important to discuss the risks of taking any medication with your doctor.

I personally have worked with several clients who have come off GLP-1 and maintained their weight loss thus far in conjunction with sustainable lifestyle and behavioral changes. 

Best Practices

Here are some non-negotiable interventions that I discuss with my clients who have started or are starting weight loss medication. 

1. Aim to have three “eating points” throughout the day. These medications cause a significant decrease in appetite especially on a higher dose. Establishing times to check in with your body and provide it with the energy that it needs to metabolically function is key to successful long-term weight loss maintenance. It’s not about eating less; it’s about eating enough.
   
2. Prioritize protein and fiber when eating. When you lose fat mass, you will likely lose muscle mass too. Include protein-rich foods like lean meats, fish, beans and dairy into meals and snacks to help minimize lean body mass loss. Fiber, found in fruits, vegetables, whole grains, nuts, and seeds, play an integral role in maintaining a healthy gut. Including fiber in meals helps manage potential symptoms of constipation and diarrhea.
   
3. Adequate hydration.
   
4. Include a multivitamin.
   
5. Regular movement. Resistance training of some sort is highly recommended.
   
6. Establish a positive relationship with food, especially if there is a history of dieting/restriction.
   
7. Establish measures of success that do not include the scale or BMI. Such measures can include improved lab values (HbA1c, cholesterol, etc.), mobility/activity level, mood, energy, the way clothes fit, etc. 

For the appropriate candidate, weight loss medications may be the catalyst to improve overall health when paired with diet and lifestyle changes. They address underlying dysregulation of appetite that makes losing weight and maintaining weight loss difficult. Ultimately, the integration of weight loss medication into your care plan is your decision. Clinically and individually assessing every client is key. It is my job to encourage you to ask the right questions, understand the risks, mechanism of action, to advocate for yourself, and most importantly, find a provider that is invested in a weight-inclusive well-being.