Translated by AIVersione italiana
4′ min read
Translated by AIVersione italiana
You lose weight quickly, often in a dramatic way. But that number on the scales doesn’t tell the whole story: from diet to mental health, from physical activity to inequalities in access to care, there is a whole world of factors that determine whether treatment with GLP-1-based medicines really works or risks neglecting important aspects of health. This is at the heart of the first major European Consensus on the correct use of the latest generation of anti-obesity drugs (GLP-1 or GLP-1/GIP-based drugs), published in The Lancet Diabetes & Endocrinology and authored by an international team of 26 experts, coordinated by Laurence Dobbie of King’s College London.
The document comes at a crucial time: semaglutide (whose patent has already expired in many countries, such as China, India, Canada, Brazil and others) and its ‘cousin’ drugs have forever changed the way obesity is treated, but their widespread use is outpacing the scientific evidence on how to manage them safely and effectively. That is why the leading scientific societies in the field – the European Association for the Study of Obesity (EASO) and the European Federation of the Associations of Dietitians (EFAD) – together with patient organisations (European Coalition for People living with Obesity) – have decided to jointly produce a comprehensive user guide, aimed at doctors, dietitians and patients, to ensure these treatments are used more correctly and effectively.
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It’s not just about kilos: what really changes in the body
One of the points highlighted by the Consensus concerns what is lost when weight is shed: existing studies show that a significant proportion of the weight lost – between 24 and 30 per cent – is lean body mass, in other words, muscle. This is something to keep an eye on, particularly in older people, who are most at risk of sarcopenia. Experts therefore suggest a benchmark: the ideal ratio of fat lost to lean body mass lost should be around 3 to 1 (i.e. for every 4 kilos lost, 3 should be fat and 1 should be lean body mass).
Hence the call to move beyond the focus on the scales (i.e. weight in kilos) and BMI (body mass index), by including in the patient’s assessment measures such as waist circumference, simple strength tests (for example, a handgrip test or the ‘sit-and-stand’ test repeated five times) and, where available, more in-depth tests such as DXA or bioimpedance analysis
It’s not just about injections or pills: diet and a psychologist are always part of the plan
One of the document’s strongest messages is that these medicines cannot simply be prescribed ‘just like that’. Medical nutritional therapy, developed by a dietitian, is described as ‘central’ to treatment rather than merely ancillary: it serves to ensure the correct intake of protein, vitamins and minerals, to alleviate the gastrointestinal side effects typical of these treatments, and to guide the patient towards a lasting change in diet, through communication that is non-judgemental and does not reduce health to a mere number on the scales.
The psychological aspect is no less important. Whilst it is true that GLP-1 medications are associated with an improvement in mental wellbeing, many people with obesity already have pre-existing psychological vulnerabilities, and the profound changes to their sense of self associated with significant weight loss can cause these to resurface. The Consensus therefore recommends that, before starting treatment, a psychologist should assess the presence of any mental health issues, including alcohol use.
Exercise also plays a role that experts wish to emphasise: any form of physical activity helps with weight loss, prevents weight regain and protects general health, but it is strength training (or ‘resistance training’), combined with aerobic exercise, that is the key to minimising the loss of lean body mass during treatment
The geographical lottery of obesity: those with less receive poorer care
The document does not limit itself to the clinical aspects of obesity treatment, but also highlights the inequalities that risk turning into discrimination. Obesity affects ethnic minorities and those from lower socio-economic backgrounds the hardest – the very same groups that also have less access to these expensive medicines
There is also a cultural issue, even before the economic one: people with obesity who have no other related conditions are often treated as ‘lower priority’ cases compared to those who have already developed complications; a sign that the stigma surrounding obesity – a condition that should be treated in its own right as a ‘disease’, and not only when it causes complications – is far from being overcome. The authors call for policies that expand coverage of these treatments and clinical services, and that ensure access to a dietitian for other members of the multidisciplinary team, in order to reduce inequalities in access to care.
Research is lagging behind: very few studies look beyond weight
What makes the issue even more urgent is a finding that emerges from a review of 417 randomised studies on incretin-based therapies: fewer than 20 per cent collected data on dietary habits or nutritional markers, and fewer than 5 per cent measured outcomes relating to bone health, micronutrients or physical function. In short, science knows full well how many kilos these drugs help people lose, but it still knows far too little about what actually happens to the bodies of those who take them in the long term.
For this reason, the authors of the Consensus call for future clinical trials to always include a set of key assessments (core outcome set), such as monitoring nutritional safety, assessing muscle function and mobility, optimal protein intake, psychological outcomes, and dose-titration strategies to reduce treatment discontinuation due to gastrointestinal disturbances, as well as ad hoc studies to assess what happens upon discontinuation of treatment or following bariatric surgery
The take-home message of the Consensus is clear: incretin-based therapies represent a genuine paradigm shift in the treatment of obesity, but to be used to their full potential they must be combined with a diet supervised by a dietitian (with constant attention to protein, fibre and fluids), resistance training and psychological support, to safeguard mental health. In short, the medication is just one part of the treatment: without the others, there is a risk of winning the battle on the scales but losing the real war – that of long-term health.
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