The Lancet Diabetes & Endocrinology recently published a consensus piece on using GLP-1 medications for obesity in Europe. The paper, “Nutritional, Functional, and Psychological Considerations for Incretin-Based Therapies in Adults—an EASO, EFAD, and ECPO Consensus Statement“, aimed to provide guidance on best practices for clinicians prescribing obesity medications — but one could argue, it’s more likely to lead clinicians to feel ill equipped than empowered.

Summarizing the paper’s recommendations, it seems to me that the vast majority would be well within the abilities of an everyday family physician, yet the guidelines explicitly discourage incretin-based therapy (GLP-1 therapy) as a stand-alone prescription. Instead, they recommend GLP-1 prescriptions be paired with dietitian-led medical nutrition therapy along with functional exercise and psychological support when warranted. 

Certainly, I wouldn’t disagree that inter-professional care is ideal. But the simple truth is that even were such care affordable and time manageable for everyone who wanted it (and of course it’s not), it wouldn’t be accessible simply on the basis of there being far more people who meet medical need criteria for GLP-1s than there are expertly trained physicians and allied health professionals available to support them. 

Most of the recommendations, though, are easily implementable by way of everyday family clinicians and are also providable in handout form. Summarizing them as succinctly as possible would include:

Key Points

• GLP-1s for obesity: consensus favors dietitian-led MNT + exercise + psych support.
• Stand-alone incretin therapy discouraged; interprofessional care preferred.
• Primary care tasks feasible: diet/allergy review, ED screening, baseline labs, wt/BMI/waist tracking.
• Monitor higher deficiency risk: elderly, low-income, post-bariatric, malabsorption comorbidity.
• Counsel long-term therapy; stopping GLP-1s usually leads to weight regain.

Which obesity patients benefit most from GLP-1 co-management?

What baseline labs predict GLP-1 nutritional complications?

How does GLP-1 therapy affect body composition long term?

• Assessing a person’s dietary patterns and allergies
• Screening for eating disorders and prior medications during and after their medication-induced weight losses
• Providing realistic counselling around expected weight loss, drug effects and side effects, and the need for long-term treatment in managing any chronic disease (meaning these drugs, like those for other chronic diseases, are long term; stopping them will lead the majority to regain weight)
• Identifying people at a higher nutritional deficiency risk (the elderly, the impoverished, prior bariatric surgical patients, people with comorbidities affecting dietary absorption) for more careful monitoring
• Recording weight, BMI, and waist-to-hip ratios
• Doing baseline nutritional blood work along with periodic follow ups
• Encouraging protein with all meals and snacks and aiming for a minimum of 60 g/d and up to 1.5 g/kg/day (I think it is wisest to calculate this based on a BMI of 30 rather than at presenting BMI) and recommending protein supplements if necessary
• Encouraging at least 25 g of fiber per day
• Managing side effects (including when necessary with other supplements or prescriptions) and counseling on common dietary triggers as well as how to deploy slower dose titrations (doctors are great at remembering and following lists, and it wouldn’t take much to educate them on this)
• Monitoring for severe dietary restrictions, adding multivitamins, increasing calories, and decreasing drug dosages where necessary
• Encouraging exercise, especially resistance training and load-bearing exercises

Not likely doable for most busy family practices but the guidelines recommend including:

• Fitness testing
• Personalized dietitian led dietary assessment and guidance
• DEXA scans
• Bio-impedance body composition measurement
• Individualized exercise programs and prescriptions
• Adapting recommendations to culture, finances, food access, cooking facilities, and available social support for every patient
• Providing professional psychological support in adjusting to changes in identity, social eating and food-based coping, and the development of alternative coping strategies

And while those not doable things would definitely provide added value to the prescription of GLP-1s, the question I’m left with is: Might it be wiser to publish a basic guide for family physicians that rather than discourage them from prescribing medications that have remarkable and ever-growing benefits for their patients, empower them to do so? That’s not to say the idealized program can’t be described, but it’s difficult to see the gatekeeping of incretin prescription by way of overcomplicated and unnecessarily robust guidelines as being a net benefit to the public.

You may not be surprised to learn that the majority of the consensus guideline’s piece are themselves working in interprofessional obesity treatment programs or are the allied health professionals the guidelines recommend be involved with patients prescribed GLP-1s. While I appreciate the value of such an interprofessional program and understand the wide-ranging challenges and implications of both obesity and weight loss, I’m not fond of the guideline authors’ approach. 

Instead, I would love to see these same experts, rather than detailing an idealized treatment course, publishing the bare bones treatment course — one that relies on the least number of medical professionals, the least number of visits, and the least number of tests and interactions while simultaneously explaining the added benefits of more involved treatment, as well as the red flag cases where more would be essential. Doing so would in turn enable the prescription of medications whose proven benefits (not just to obesity but to an ever-growing list of comorbidities and ancillary risks) without question vastly exceed the risks of nonidealized support.