GLP-1 Access: What Clinicians Need to Know and What RDNs Want to Understand, Pt 4
This episode of Nutrition411 explores how clinicians and dietitians can set realistic, emotionally informed expectations for patients using GLP-1 medications for obesity, emphasizing that obesity is a complex, multi-layered disease with significant psychological components.
The discussion between Lisa Jones, MA, RDN, LDN, FAND and Bonnie Chambers, MSN, FNP-C, highlights targeting slow, steady weight loss of about one to two pounds per week, avoiding overly rapid loss, and adjusting medication doses based on progress while prioritizing adequate protein, fluids, and strength training to support healthy, sustainable outcomes and preserve muscle mass. The conversation also addresses how to counsel patients through plateaus, side effects, and insurance or supply interruptions by framing GLP-1s as one tool among many.
Transcript
Lisa Jones, MA, RDN, LDN, FAND: And we're back. We're back with another episode with Bonnie Chambers. Today we're going to be talking about setting realistic expectations. And Bonnie, last time we talked about understanding the clinical details and help dieticians bring more empathy and precision to their care. So let's wrap up this series by talking about how to set realistic expectations and support patients through the emotional side of this process because there is some emotion here, right?
Bonnie Chambers, MSN, FNP-C: Oh, there's a lot of emotion 100%. Obesity is such a complex disease. It's multi-layered and there's definitely an emotional and psychological element there. So as far as goals for patients, again, I'll tell them when we're starting therapy that the goal is one to two pounds of weight loss a week. We don't want more than that. If you're not quite there, then we probably need to keep increasing that dose. But if you are there, then we should stay at that current dose for a while. And then making sure, again, that hitting their nutritional goals, getting their protein. My patients are probably so sick of me hearing me say, "Are you getting your protein and your fluids?" versus, "Are you physically doing okay?” “Are you getting your protein in your fluids? Are you doing your strength training?" But it's something that you really do have to keep continuing to assess and reevaluate because that risk is there. And we want people to have healthy, sustainable weight loss and these medications are just a tool in the toolbox.
Jones: That's so important and you want to make sure this is a lifestyle change. So how could you set them up for success? And then thinking about what are their expectations and which ones do you try to set from the beginning, from as soon as they start on the medication?
Chambers: Yeah. So I'm not a big goal weight person. If a patient wants to, I will have that conversation, "Do you have a goal?" If they do, that's great. I just ask them to try to keep an open mind and be flexible there because a lot of things come into play with weight, especially age and muscle mass and all that. So I think, again, it's just slow, steady, healthy weight loss, no bad side effects, doing what you need to do overall for your health, doing check-ins with the RD, having follow-ups with the other medical professionals. If there's emotional eating involved, that needs to be addressed and treated also. So we have where I practice a great behavioral health team and there's great behavioral health teams in many, many places. So just I think it's very important, again, that communication thing. When we're starting a patient on these medications, setting very clear, specific goals as far as the weight loss, but also the type of weight loss that we want.
Jones: Yeah, that's important too. Because I think the other thing too, and you mentioned it earlier in one of the other episodes, but you were talking about a little bit about food noise. Food noise. I think that's a huge thing for a lot of the patients experience and they're like, "Well, as soon as I started taking the GLP-1, the food noise went away."
Chambers: Right. And so I'll have that conversation honestly because it is amazing. First of all, food noise, I think if you don't understand obesity, the diagnosis of obesity, you may not understand how real food noise is. It is a real thing. And these GLP-1 medications are the first medications out there that you just see a drastic reduction or elimination in food noise, which is wonderful. Patients say it just went away and it's been relieved. But with that, because you get that reduction in the food noise, but also these medications, you'll get to a point where you just won't think to eat. It's like almost after having bariatric surgery, you have to set reminders for yourself to make sure that you have to just be very mindful of your, again, protein and fluids, love those, but everything that you're eating a nice, well-rounded, healthy diet and you may need to do meal planning, thinking ahead, making sure, having that structure in your day to make sure that you're getting there because you may not necessarily have those cues anymore reminding you to do that. So you need to reinforce it with a little planning.
Jones: Yeah, it's definitely a plan. You got to plan everything out because that's where you can fall back on, okay, if I don't plan, then it's a convenience food where I don't really want to, that's not the healthiest thing to be doing. So making sure that ... Yeah. How about messages? What messages do you find that are most effective for helping patients, especially when they have a plateau or there are side effects or maybe even supply interruptions? Like with your Medicaid patient that was just told it's not covered, maybe they had a supply because they couldn't ... I don't know. I'm just saying maybe they didn't want to spend the money on it, self-pay, so they have a supply interruption.
Chambers: So what messages do I send those patients?
Jones: Yeah. What message do you find effective for helping them stay grounded so they're not ... Because I know back before we even had GLP-1s, dieticians would have to work on the messaging. We'd have like say we had a client that was on a weight loss plan, and two weeks in a row they stayed at the same weight and they were all upset because they were like, "This plan isn't working. Give me another plan”
Chambers: So I tell my patients, I don't really consider a weight loss stall or plateau until it's four or five weeks in, just because hormones and stuff like that come into play. And I think it's really important to emphasize the fact with patients that these medications, again, they're a tool in the toolbox. If you cannot start these medications, it's not feasible right now, it's not covered, then we're going to talk about all the other options that are there for you and figure something out to help you get what you need.
So it can be an anxiety-driven type of area just because there's a lot of you don't know and these medications just are so good and so helpful. If someone loses coverage for it, it's emotional because they're afraid that the food noise is going to come back and it's not just about the weight, it's about their overall health because of all the improvements people see in their health and all the blood pressure and cholesterol and everything else, A1C with the weight loss and with these medications. So I think it's just really important when interacting with people to do what you can, see if you can get them on the GLP-1s, but then make sure they know that it's not the end of the world that there are other things we can do to help and that things are constantly changing. And just because it's not covered now doesn't mean it won't be covered in six months because every July and January becomes a heck of a month for me because everything is in July and January, so you never know.
Jones: So July and January, it's safe to say, Bonnie, that they're not your favorite months.
Chambers: This July was my CVS CareMark month, and January is my Medicaid month. So we'll see what next July is.
Jones: Which- Well, is there any chance that they're going to, and I hate to say this, but change their mind?
Chambers: Absolutely. There's a chance. And again, I don't know this to be for fact, but I'm pretty sure it has to do with cost. So I think when cost, if cost continues to come down, which it will inevitably, to be competitive, they're going to have to bring the cost down. And also there's going to be more new agents coming out. There should be a Zepbound pill coming out. There should be some triple agent type of medications coming out on the market that there's definitely things on the horizon that will come out with a higher cost or something. And then the other ones will drop in cost. I mean, I'm not an economic type person, but it makes sense to me.
Jones: Yeah. And then they'll be like, "Okay, we'll cover this one."
Chambers: Exactly. I'll see that they're covering liraglutide or Saxenda, which is the daily injection that was the predecessor to the weekly Wegovy and Zepbound. So that is not quite as effective, but there are some plans now that we're not covering any type of the injections, but are now going to cover that one. And again, I think it's a cost issue. Yeah.
Jones: Yeah, but that's good though. It sounds like from where we were when these medications initially came out, it's a better place. It's improving. It's just not improving as fast as we'd like it to improve maybe. The access is slower to come.
Chambers: Yes, exactly. It is definitely improving. I mean, we have steps back too with the drop coverage and everything, but as far as the out- of-pocket cost, it is not going to go up. It is only going to go down. So at least we know that. And hopefully with that will come also more insurance coverage of the medications also.
Jones: Yeah, I hope so too. Thank you. Well, how about for our last question, we talk about RDNs and what would be one practical or mindset-based takeaway that they can then use to better support their GLP-1 patients or clients?
Chambers: I just think what you guys do as part of the care team is just so very important and I'm so thankful for that to have that nutritional support and expertise provided to our patients. It is just so important that, again, healthy weight loss and they're getting what they need and they're eating and they're drinking fluids, healthy fluids, water, and that you're there to reinforce that and give them ideas on different ways to make sure that they are meeting those goals and getting what they need. So I think we just work together, but to help all our patients have that healthy weight loss, but you guys are really the experts in providing those dietary suggestions that help get these patients to where they need to be. So I would say just thank you for doing that and just helping patients be mindful. Muscle mass is a big thing. We want to make sure not losing muscle mass, strength training, protein. And also, please never be afraid to reach out or communicate with someone who is prescribing the medication because we want to hear it. If you're concerned, that's valid and absolutely something that we will actively follow up on with the patient and are grateful to have that feedback every single time. So never hesitate also.
Jones: I love that, Bonnie. Thank you so much. That's fantastic. And thank you for sharing all of your insights and experiences with us over the course of these three episodes. And we're helping bridge the gap between clinical management and patient care. And thank you to our listeners for joining another episode of Nutrition411, the podcast. Be sure to subscribe for more conversations that connect the science, psychology, and strategies of modern dietetics. Until next time, take care and stay curious.