“Beyond BMI”: Emerging weight loss guidelines emphasize holistic health care

Focusing only on weight loss for those with a high BMI (body mass index) may do more harm than good, new research warns. With the rise of GLP-1 drugs offering rapid weight loss, we speak with the study’s co-author about the importance of holistic care for obese patients amid the rising trend of weight-loss medications.

Juan Victor Ariel Franco, MD, MSc, Ph.D., tells Nutrition Insight that lifestyle interventions, such as restricting energy intake and increasing physical activity, have been proven ineffective in long-term weight loss, reducing heart issues, and preventing mortality. The American College of Cardiology recently echoed this conclusion in a statement, which goes against traditional recommendations for weight loss.

The study, published in The BMJ, stresses the value of personalized, high-quality, and evidence-based care that doctors should provide regardless of weight.

GLP-1 RA for the long term?

There is a wave of anti-obesity drugs, especially in the US. Amid this growing popularity, Franco highlights his concerns about conversations on fast weight loss.

“The effects of GLP-1 receptor agonists (RA) extend beyond weight loss, offering improvements in several metabolic parameters — areas where previous drugs and lifestyle programs for obesity have often fallen short.”

“Nonetheless, the most significant weight loss typically occurs during the first year, with a plateau commonly observed in the second year,” he cautions. “Importantly, almost complete weight regain is expected after discontinuation of the medication, which raises concerns about the long-term sustainability of these therapies.”

Health, drug, and nutrition intersections

Weight-loss drugs are moving to the front line of obesity care. However, Franco stresses that healthy behaviors and nutrition remain essential for improving clinical outcomes.

Lifestyle interventions, such as restricting energy intake and increasing physical activity, have been proven ineffective in long-term weight loss.“The challenge lies in how to effectively achieve and maintain them. Most behavior change programs have had limited success, largely because long-standing habits, cultural factors, and socioeconomic conditions deeply influence them.”

“These elements are difficult to address in the context of routine clinical consultations, often resulting in frustration for both patients and healthcare providers. Public health strategies and broader societal interventions are, therefore, crucial in this space,” he advises.

The latest guidance for clinicians by the American College of Cardiology (ACC) recommends the use of weight management medications as a first-line treatment for obese patients to reduce cardiovascular disease (CVD) risks.

It notes that GLP-1s like semaglutide and tirzepatide are more effective than lifestyle interventions for weight loss and lowering CVD risks. The ACC also claims these medications have fewer risks than procedure-based interventions, contradicting previous guidance recommending patients try lifestyle interventions such as diet and exercise before beginning medication.

With updates to clinician guides on approaching heart health and weight loss, Franco discusses the risks of positioning medication as a first-line treatment.

“The problem lies with the idea of ‘before.’ We should be addressing all aspects of healthy living simultaneously. This includes improving access to nutritious food, creating environments that support physical activity, and reducing discrimination based on weight.”

“We need targeted, person-centered interventions that go beyond nutrition alone, meeting individuals where they are and supporting them in achieving their health goals,” he states.

Exploring alternatives

Given that lifestyle interventions are generally ineffective, according to the study, Franco discusses alternatives to tackling obesity that don’t just focus on weight loss.

Juan stresses we need targeted, person-centered interventions that go beyond nutrition alone to meet desired health goals.“Our recent publication highlights the importance of recognizing weight bias — the negative attitudes toward individuals living with obesity. If someone expresses a desire to lose weight, we should support them, but through a person-centered approach rather than a one-size-fits-all model.”

“Current guidelines often assume that weight loss is the primary goal for all individuals with obesity, which reflects an underlying bias. Instead, we must support people in pursuing their own health-related goals, which may include adopting healthier behaviors, improving their overall well-being, and, if they wish, losing weight.”

Recently, US organizations developed the advisory “Nutritional Priorities to Support GLP-1 Therapy for Obesity” to help clinicians support patients in weight management with evidence-based nutritional and behavioral strategies.

Achieving respectful care 

Franco stresses doctors should consider all the options, including GLP-1 RA, as the effectiveness of an intervention depends on the individual.

“If people feel supported — not coerced — by the healthcare system, we can foster long-term, compassionate, and respectful care, which they truly deserve,” he says.

The paper notes an alternative weight-inclusive approach, including Health at Every Size, a center that recognizes the social determinants of health, which can be achieved regardless of weight loss. Its approaches involve intuitive eating and enjoyable physical activity, which the study says have shown promising results.

Meanwhile, as US Health Secretary Robert F. Kennedy Jr. intends to make nutrition education compulsory in medical schools, with the risk of losing federal funding, we looked at the need for better training in nutrition while ensuring nutrition remains grounded in science.

Researchers highlight that mainstream medicine’s focus on linking weight to health and BMI does not accurately reveal health status and suggest doctors focus more on cardiometabolic health. If benefits arise independent of weight loss, physicians should shift conversations with patients to emphasize health over weight loss.