Experts develop new nutritional guidelines for patients on anti-obesity drugs

11 Jun 2024 --- Dietary quality is essential for patients on anti-obesity medications as they commonly experience reduced appetite and, as a result, lower food intake. Based on a narrative review, medical experts have developed a list of evidence-based nutritional recommendations to assist clinicians in treating patients on these drugs.

The guidelines support nutrition assessment, management and monitoring of patients treated with anti-obesity medications. The authors underscore that clinicians can play an “active role in supporting their patients with obesity to improve their health and well-being and promote optimal nutritional and medical outcomes.” 

“Our evidence-based review aims to equip clinicians with knowledge and tools to help support optimal nutritional and medical outcomes for their patients treated with anti-obesity medications,” says Lisa M. Neff, executive director of global medical affairs at the pharmaceutical producer, Eli Lilly and Company, and corresponding author of the review. 

Before treatment, clinicians should identify pre-existing nutritional risk factors and advise their patients on the recommended protein, fiber, micronutrients and fluid intake. 

The review authors assert that ongoing monitoring during treatment can facilitate early recognition and management of gastrointestinal symptoms and inadequate nutrient or fluid consumption. Clinicians must also pay attention to other factors that may impact treatment response and quality of life, including physical activity and social and emotional health. 

Healthy dietary patterns 
The study, published in Obesity, reviewed articles on nutrition and diets for weight loss and obesity, very low-calorie diets, malnutrition and bariatric surgery. Eli Lilly and Company funded the research. 

The experts provide nutritional recommendations for total energy intake and consuming protein, carbohydrates, fats, fiber, fluids and micronutrients. 

They note that clinicians must personalize minimum energy intake goals across patients as requirements vary based on someone’s age, sex, body weight and physical activity levels, among others. Safe energy intake levels are generally recommended at 1,200 to 1,500 kcal per day for women and 1,500–1,800 kcal per day for men. 

The recommendations cover total energy intake, protein, carbohydrates, fats, fiber, fluids and micronutrients.Recommended protein sources include beans, lentils and peas; nuts, seed and soy products; seafood; lean meat; poultry; low-fat dairy foods and eggs. Protein intake should be around 0.8–1.5 g per kg of body weight daily. 

The authors note that carbohydrates should comprise 45–46% of energy intake, with recommended sources of whole grains, fruits, vegetables, nuts, seeds and dairy products. They recommend limiting added sugars to less than 10% of energy intake. 

Fats should account for 20–35% of energy intake. To decrease gastrointestinal side effects associated with anti-obesity medications, patients should focus on nuts and seeds, avocado, vegetable oils, fatty fish and seafood, while avoiding fried and high-fat foods. 

Women should consume 21–25 g a day of fiber and men 30–38 g a day, depending on age. If patients cannot meet their goals with food alone, such as through fruits, vegetables and whole grains, they may consider supplements. 

Patients should consume two to three liters of fluids daily, mainly water, low-calorie beverages such as unsweetened coffee or tea, or nutrient-dense beverages like low-fat dairy or soy alternatives. The researchers recommend limiting or avoiding caffeine intake due to its potential diuretic effect. 

People with obesity are at a higher risk of micronutrient deficiencies, such as vitamin D, folate and thiamine. In addition, potassium, calcium and vitamin D are of public health concern for US adults, iron for women of childbearing age and vitamin B12 for older adults. The recommendations suggest using a complete multivitamin, calcium or vitamin D as appropriate. 

Ask, assess, advise, agree and assist 
The authors recommend using a “5A Model” — ask, assess, advise, agree and assist — in working with patients. Clinicians need to ask permission before talking to patients about weight loss. 

Patient assessments should include a complete medical history. Clinicians should assess psychosocial, weight, dietary and other lifestyle history aspects, including a physical examination and lab or imaging studies to determine the root causes of obesity. Moreover, they should identify obesity-related complications and assess nutritional status, including malnutrition risk. 

Moreover, the paper suggests that clinicians advise patients about treatment options and expectations. They should also agree with patients on health goals, dietary and lifestyle patterns and weight. 

Next, clinicians should assist patients in overcoming barriers, address challenges to weight management, and arrange follow-up care or refer patients for additional support, such as meeting with a registered dietitian. 

Other factors that may impact treatment response and quality of life include physical activity and emotional health.Weight loss support 
The review authors note there is limited evidence to guide nutritional recommendations for patients on anti-obesity drugs who lose 15% or more of body weight. 

Last month, the British Dietetic Association and the British Nutrition Foundation also called for holistic support for anti-obesity drugs, such as supporting nutrition and physical activity.

“Simply focusing on weight loss is insufficient for optimal health,” agrees Dr. Jessica Alvarez, associate professor of medicine at Emory University School of Medicine, Atlanta, US, not associated with the review paper. 

“People with obesity are already at risk for some nutrient deficiencies,” she adds. “This is an important guide acknowledging the need for thorough nutritional assessment before and during treatment with anti-obesity medications.”  

“Many patients need detailed guidance on what and how much to eat to ensure optimal diet quality, avoid nutrient deficiencies and avoid excessive muscle loss while taking anti-obesity medications. This work also highlights the need for rigorous clinical research to establish dietary recommendations for people being treated with anti-obesity medications.”

Companies increasingly develop tailored products to support patients using anti-obesity drugs such as glucagon-like peptide-1 (GLP-1) receptor agonist medications. For example, Noom unveiled a muscle fitness program for people on these drugs, while Nestlé created a high protein portion-aligned food to complement the diets of weight loss medication users. 

By Jolanda van Hal