Like any clinician working in 21st century American healthcare, over the last 12 months, I've come in contact with an explosion of patients taking GLP-1 semiglutide medications. While those medications were initially labeled for diabetic control, the vast majority of cases presenting in my office are for weight loss. And like many colleagues in the integrated space, balancing the facts about the benefits of a medication addressing severe persistent medically dangerous obesity with known and unknown side effects has been a fine balancing act.
Behind closed doors, when colleagues and I candidly discuss our experience with patients taking this new class of medication, we all wonder when the proverbial other shoe will fall off. There has been an unbridled enthusiasm about the potential for those medication to help curb the scourge of chronic population obesity, but probably a bit of a vacuum when it comes to discussing all of the pros and cons of the prolonged use of a class of medication that historically had been reserved for the patient with poorly controlled diabetes. After 30 years in practice, you acquire a little bit of healthy cynicism when it comes to new treatments of any sort, knowing that some downfalls are not readily available during the "honeymoon" period of a launch that can take months to years to unfold.
There may be a bit of the proverbial shoe starting to drop based on the most recent article published in Lancet (1 of the top dogs of straightforward published medical research). The speed at which patients can lose weight, it turns out, is not all about tissue that you would want to shed. A whopping 3rd of the weight loss comes from lean muscle tissue. This is in contrast to nonmedically induced weight loss from calorie restriction and physical activity, which has a much better track record at preserving lean muscle mass. The latter is quite important for long-term weight maintenance, since muscle tissue is much more metabolically active at burning calories at rest, acting as a blood sugar buffer, among other things.
From a neuromusculoskeletal provider standpoint, the research article hit a bit of a raw nerve because of the implications for our treatment plan. I had already started to suspect that patients on long-term GLP-1 exhibiting significant weight loss were also presenting with decreased overall muscle tone, bulk and endurance, complicating the stabilization phase of the typical spinal and extremity pain that were trying to treat. Another aspect of the rapid weight loss involving muscle tissue that is not brought up by Lancet but is a big concern to me is the concurrent potential impact on decreased bone mass. Lean muscle mass loss and bone loss tend to go hand in hand during significant weight loss.
The research article has reminded me of the importance of reviewing with patients 3 important mitigating strategies with patients on long-term GLP-1:
incorporate a sufficient amount of protein in the diet while on the medication, defined as a minimum of half a gram of protein per pound of body weight. This means that a 200 pound adult would need 100 g of protein. You have to be really intentional about reaching that goal every day through combination of protein dense foods with every meal, and potentially supplemental protein.
Engage in resistance training to 3 times a week that is sufficient to stimulate muscle growth. Just doing activities of daily living and walking is not going to preserve muscle mass.
Consider adding a good bone building support supplement, which is going to contain a combination of bioavailable calcium, magnesium, other bone building minerals, vitamin D3 and vitamin K 2.
