GLP-1 Access and Patient Expectations, Pt. 2

In this episode of Nutrition 411, host Lisa Jones, MA, RDN, LDN, FAND, is joined by Caroline Susie, RDN, LD, to examine how GLP-1 medications are transforming patient expectations in weight management. They discuss the rapid rise in demand, evolving access pathways, and the challenges clinicians face in ensuring appropriate use. The conversation highlights the critical role of dietitians in reinforcing foundational nutrition principles, supporting long-term success, and addressing misinformation in an increasingly complex and fast-moving treatment landscape.

TRANSCRIPT

Lisa Jones, MA, RDN, LDN, FAND: All right. And welcome back to another episode. While the national guidance is evolving, so is the clinical landscape. And I'm talking about particularly with increased awareness and access to what we're all talking about now these days is GLP-1 medications. So we want to really explore how that's shaping conversations in the counseling room. So this episode, Carolyn, thank you so much for coming back to hang out with us again. It is called GLP-1 Access and Patient Expectations. And my first question for you is, you work extensively in adult weight management. How has the rise of these medications shifted the expectations that patients bring into sessions?

Caroline Susie, RDN, LD I mean, two words, game changer. Game changer. I mean, I just feel like in a world of where we can get on our phones and have something delivered later that day, whether it's food or a beauty product or Tide detergent or whatever, we live in this world of instant gratification, and these medications absolutely check that box because the results are so incredible and you see these results rather quickly. It's just in the world of obesity treatment, this has just been so incredibly exciting. On the flip side, not to be negative, Lisa, but yeah, I mean, I feel like it's like the '90s again. Lindsay Lohan back and what was it? It was Lindsay Lohan and Brittany Spears and Paris Hilton, and they were leaving the club. That's where we're living. And it's like this skinny, very thin, the emphasis on being very thin is back. And I think it all hurts our dietician hearts that there's such an emphasis on this.

So again, dieticians, time to shine, talk about how these medications work, who they're intended for, and why they really probably aren't appropriate for everybody, particularly our patients that are just seeking five or 10 pound weight loss goals. I think there's a lot of pressure to find a prescribing provider or go to these digital clinics that can get these medications. And again, I do think that addressing how the medications work and who they're intended for and maybe long-term, how we can tee patients better for success, I think this is, again, dietician's time to shine.

Jones: Yes, I couldn't agree more with that, with our time to shine. But one of the questions I'm thinking as you were talking through that is there's all these commercials, and I'm not going to say any brand names, but they're like the commercials about the GLP-1s, how you can sign up and all you do is have to meet with the physician and then you can get your medication delivered to you. Do you think that it's easy for somebody that doesn't necessarily meet the criteria to get the medication? Because I thought that they still had to have that approval of that physician or nurse practitioner to put that through.

Susie: I mean, first of all, the commercials are hilarious. It's like everyone's dancing around, we're doing a dance and we're smiling, and then they list all the side effects, but people are still happy and living their best life. So I would like to think that every patient living with OPC is meeting with a prescribing provider who in addition to being an MD has this additional certification of being board certified in obesity. That's not the reality. Understood. Even better if they referred to a dietician that had this additional certification for working with patients with obesity.

I think that you are getting some, however you want to position this, perhaps some digital clinics out there that perhaps are more opportunistic versus clinically rigorous, which can be a little frustrating. But in theory, the patient still needs to meet the FDA requirements of the body mass index of 30 or greater or 27 with other weight-related conditions, so elevated glucose, blood pressure, whatever. There are various digital clinics that are probably a little stricter than others. I have to step on a smart scale or verify my height. I have to upload a picture of my driver's license. It's all over the place and how these digital clinics are going about it. I think in the brick and mortar, I sound like an attorney, and sorry if anybody listening is an attorney or you're married to one, but it really depends. It really depends on who that prescribing provider is.

Are they going to meet the patient ask and do we want to "microdose," which we can talk about that next, but microdose or compound, or are we really following what the FDA indicators are for? And this patient meets these criteria. They have six months of history where they have had serious weight loss attempts that have not been fruitful. We've tried other medications. This patient is a perfect candidate for this. I just think given the popularity and given the statistics of how many Americans have tried these drugs, there has to be some bad apples there in prescribing.

Jones: Oh, definitely. And one thing that popped in my mind when you were talking about that is especially the ones that are online, how do they prove how...You could basically say, "This is how much I weigh," and it's not correct because how are they proving that unless you took a photo of yourself on a scale with the number? I don't know, but you could put your friend Susie on there if you wanted to.

Susie: Right. And be like, "Oh, I'm five feet. I'm not 5'7"." At least in the employer space, what we are seeing is patients have to obviously complete lab work before receiving these medications. And during that lab visit, there is an opportunity to be in person to verify height and weight, or the patient is shipped a smart scale or the patient has to upload their driver's license, which also I'm like, I don't even know what my driver's license says, frankly, it's probably expired. So I think they're trying to have some of these precautions in place in the spirit of patient safety, but yeah, I'm sure unfortunately there probably are some loopholes. And in my experience, if a patient wants these medications, they will tend to go through every hoop possible to receive these medications.

Jones: Yeah, that makes sense. Definitely. And the other thing too is cost. So they're expensive, but then the ones that the commercials I've been seeing lately make it seem like-

Susie: It's doable.

Jones: It's more affordable than if you went to the manufacturer because they say go direct.

Susie: Yeah, so the space is changing so fast. It is every day, I feel like there's a different announcement. So according to Mercer, it's a consulting firm, Mercer National Survey Data, about half of employers today are covering these medication for weight loss, and about half of Americans are getting their insurance through their employer. So if you are a dietician listening to this and you're wanting reimbursement, look into that with the insurance companies. But given that half of employers aren't covering or the other half of patients that are not receiving insurance through their carrier, what we've tend to see is there's a lot of direct to consumer either through a vendor or there's direct consumer through the manufacturer, or now we have TrumpRX, which is launching. But I think what the common theme between however you slice it, it tends to see, we see that first month be at a lower price point, but then as you go on,

The prices are kind of pretty in line with what we're seeing manufacturers charging. So I think it's frustrating. It is. It's very frustrating. And my hope is generics aren't going to be here until probably 2030 or 2031. We were really hopeful that the oral medication that has just come out, the oral Wegovy would lower the price point because it's not an injectable, so you're not paying for the pen. But what the experience so far, it has been running, at least for employer funded, self-funded health plans, it's been running about the same price as the injectable. So I'm anxious to see what the manufacturers will do. I'm anxious to see what the pharmacy benefit managers will do. That's like the CVS and OptumRx and ESI Evernorth. Again, for people that are getting insurance through their employer, those are probably the big three that are in the pharmacy benefit manager space.

But when you think about how expensive they are, the employers are really trying to balance empathy with economics. No one's doubting these drugs are incredible, but because the cost is so high, there's a lot of conversation about return of investment for employers when really would we see the savings. No one's arguing that they're incredible and we're seeing these great outcomes and that cascade a positive health reaction, but is your employee, how long are they going to take this and are they still going to be here? And how do I validate, okay, Lisa's not going to have a heart attack now. There's just a lot of questions around it. And I don't envy decision makers there because I think it's a very, again, balancing empathy with economics and then also challenging for folks that it's not covered through their employer or they're not on employer, they're not getting their insurance through their employer because the cost, I mean, it's absolutely a barrier.

Jones: Yeah. And then that brings me to my next question, which is how do we balance acknowledging the role of pharmacotherapy while reinforcing this whole thing with foundational nutrition principles?

Susie: My biggest thing, give me a megaphone, Lisa, I want to scream this. It's not the medication, it's the medication. And these drugs are meant to be taken in conjunction with lifestyle support. And this isn't like, "Okay, everybody, get your measuring cups. We're all going to measure a half a cup of oatmeal for breakfast." No. And every dietician, I hope you're raising your hands and clapping with this.

We know how complex these patients are and we know how serious these medications are. How do we help mitigate side effects for patients? How do we identify if a patient is a non-responder? Can you imagine anything worse? You've just shelled out all this money and you're one of the few that isn't responding, or the weight loss is too rapid. Ensuring that the patient's meeting their protein goals, ensuring that they're meeting their fiber goals. I would love for the indicators to be it's the medication and here's your consult with a registered licensed dietician. I think that at least in the employer space, we're seeing a lot of solutions bring in dieticians to help support patients. I mean, everybody listening to this, we're probably all being the church lady and nodding our heads right now, that a dietician, you are going to see more success when you take this medication and you incorporate the education coming from dieticians. Again, because you're teeing the patient up for that long-term success, which is exactly what we want.

Jones: Yes, diet and exercise. I mean, you have to improve your diet if you expect to make these lifestyle change or you'd be same back in the same place you were before you started pre-medication. Yep. So great points. So how about dieticians that are then assessing nutritionally when working with these patients that are using these medications, particular in relationship to the adequacy, we talk about the muscle preservation and then long-term sustainability.

Susie: So I'm going to go backwards. So the medications, obesity is a disease, these medications are meant to be taken long-term. That's where we are right now. Just like you would take a statin if you were living with hyperlipidemia. However, the market says, no, thank you. I do not want to inject myself every week for the rest of my life. What's the game plan for me to off-ramp this situation? How do I taper down an off-ramp? So while that's not in line with the literature right now, the market utilizers are suggesting otherwise. Again, insert the dietician. When you're taking something that suppresses your appetite and then you just stop and your appetite comes back, how can we help patients manage that? So I think from the long-term sustainability side of the house, I mean, I think we have a huge opportunity. For patients that are actively taking this now, muscle preservation's the name of the game.

You're losing weight so rapidly in a perfect world, wouldn't that be great if you just did not lose your lean body mass, but we all don't.

It's very sad. So we want to preserve lean body mass as much as we can. We can refer to our friends in exercise physiology to help with all of the exercise side of the house, but from a dietary perspective, what can we do to help patients meet their protein goals and also meet their fiber goals? I mean, I feel like protein and fiber is what you have to talk about with these patients, and it is really challenging because essentially it is suppressing their appetite. So reminding them when to eat. When they do eat, this is what we want you to choose so that they don't become deficient in any vitamins or minerals. And again, they're hitting those goals and preserving as much lean body mass as possible.

Jones: Yes, yes. That's so important. Strength training too pops in my head. It was one of those things that if you're not doing it, start.

Susie: A hundred percent. Even if you're not taking these medications, ladies have a certain aid. I joke all the time, you got to lift something other than your wine and gas wine house. I'm telling you, weight resistance training is the key to youth. Yes.

Everybody call your personal trainer because we need them.

Jones: Yes. Thank you, Caroline. Thank you for granting this conversation really in what's actually happening in clinical practice. I think that's really helpful. So thank you for being on this episode.

Susie: Thanks for having me.

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