Episode Transcript
[00:00:01] Speaker A: Welcome to Obesity a Disease, the official Obesity Medicine association podcast exploring the many facets of the disease of Obesity A Disease podcast is brought to you by the Obesity Medicine Association. A clinical leader in obesity medicine.
[00:00:28] Speaker B: A 56 year old female with depression, migraine headache, scurd and class three obesity has been on Turzepatide as part of her obesity treatment plan. Previously, she was hungry all the time, with constant thoughts about food. On the medication, she's no longer hungry and she doesn't even think about food. She frequently skips meals, never liked vegetables and refuses to try them. Activity is limited to walking at work, about 7,000 steps a day.
She's not interested in strength training. Over the next year and a half, she lost 102 pounds. BMI went from 42.6 to 22.9. Her fat mass went from 124 to 47 pounds, losing 77 pounds. And her muscle mass went from 117 to 94 pounds, losing 23 pounds or a little less than 25%.
So she's had excellent weight loss. Muscle mass is relatively proportionate, but her lifestyle efforts leave much to be desired.
These types of situations leave clinicians in a dilemma. Should she continue treatment? If so, at what dose? What nutritional advice should be Provided?
Hi, I'm Dr. Nick Pennings, professor of Family Medicine at the Campbell University School of Osteopathic Medicine and Director of Clinical Education for the Obesity Medicine Association. And with me is sue davaindia Benson Davies, PhD. Dr. Davies is presenting at the 2026 OMA Annual Conference. The title of her talk is Critical Thinking in Health Outcomes that Matter. But today's topic is In Nutrition and the Nutrition of the in the era of the GLP1s.
So, sue, tell us about yourself.
[00:02:13] Speaker C: Oh, well, thank you very much, Dr. Pennings, and for inviting me as your guest today.
And I'd like to also say hello and welcome to our listeners on this nutrition podcast. My background actually consists of more than 30 years in academics, nutrition research, and a lot of hours in clinical practice.
My research focus has been on body composition in addition to resting metabolic rate, specifically in bariatric surgical patients through the Sanford School of Medicine at the University of South Dakota.
So with that, I've really enjoyed working in the field of obesity and it's been a great time in my career to see clinical nutrition and food science evolving in this new era of obesity medications.
So it's a pleasure to be here
[00:03:14] Speaker B: and thank you again and thank you for being here. And so I would imagine that this type of a case is similar to maybe sometimes what you would see in a post bariatric surgery patient.
But how would you say the GLP1 therapies are changing what clinicians should prioritize in terms of nutritional advice in patients with obesity?
[00:03:40] Speaker C: Oh, that's an excellent question. And you know, I do agree we need to be thinking about some fundamental shifts in our nutrition priorities, especially with thinking about the micronutrient deficiencies that might be occurring with the lack of interest in eating.
Secondly, certainly the muscle mass and consuming a high quality protein intake to help preserve some of that muscle mass.
And thirdly, you know, that mentioned as you did in the case, nutrient density, very important as our caloric intake seems to decrease significantly in these patients on the medications.
[00:04:28] Speaker B: Yeah, I would say that there's been quite a paradigm shift, at least for me as an obesity medicine specialist. It was always emphasizing reducing caloric intake and cutting back on the number of calories that were being consumed. But now we're seeing really a different shift that I am making sure my patients are eating enough. And not only that they're eating enough. One of the things I emphasize is that the, when you cut back the total daily caloric intake, the quality of the nutrients becomes so much more important.
[00:05:02] Speaker C: You're absolutely right.
And I think we're seeing that across different clinical practices. So in order to compensate for that, I really think it's important to have a multidisciplinary team to kind of help out in guiding these patients, especially registered dietitians. What does quality nutrition look like?
How does that vary from what the patient is used to eating?
And how do we counsel and educate them on nutrition to make better food choices within that spectrum?
[00:05:42] Speaker B: So, yes. So with the profound appetite suppression that we can see with some of these agents, what are you seeing or what do you think are some of the biggest risks of undernutrition? And what kind of things should clinicians be addressing proactively to prevent them?
[00:06:01] Speaker C: Oh, excellent question. And certainly there's three different areas that I think of. First is the loss of muscle and bone mass. And so we know the skeletal muscle mass losing significant amounts of that through reduced caloric intake and reduced protein intake can cause some adverse effects, such as the physical impairment, decreased muscle quality and quantity, leading to falls and more fractures.
And in the long term, this could also lead to a decrease in the quality of life.
When we talk about bone health, that's also a very important factor to think about with the GLP1 therapies. And in fact, we're seeing some reports in randomized trials that the bone mineral density is decreased.
And this is a particular concern when we're working with our older adults and those that may have a baseline of sarcopenic obesity or osteoporosis.
The second area I think we've already touched on are some of the micronutrient deficiencies. Especially at best baseline, this population of individuals tend to have more deficiencies in vitamin D, higher deficiency rate in iron, and again, we need to look at B12, especially if they've been taking metformin in the past.
The third area we've touched on as well is this decreased desire to eat causing a lack of hunger for longer periods of time. So with that, also if they don't have a desire to eat, we're seeing changes in the smell and the taste and the texture.
These things are also responses that are important for us to be interested in eating.
So I think the whole complex of undernutrition, it can be very extreme for some patients. And so we do need to do better with our education, maybe involve a better multidisciplinary team approach to help address some of these specific concerns.
Prevention, again, baseline. Absolutely. I think we need to be screening more for the behavioral health aspect of things, disordered eating behaviors that might also be associated the mental health concerns. Looking at some of those medications that might also be inhibiting some of this desire to eat eat.
Certainly that a thorough nutrition assessment at baseline. And I know my history in working with bariatric surgery patients, an assessment can easily take an hour as these patients can be very complex.
In their whole history of weight, what has their micronutrient status been, their body composition and those kinds of things.
Another proactive strategy, of course, is looking at their protein targets. We want to make sure that they're eating adequate amount of protein within their diet. In addition to the exercise, supplementation of the micronutrients would be important as a strategy. A high quality multivitamin supplement would certainly be a good consideration as well as correcting any vitamin D or calcium or any B12 deficiencies.
[00:09:59] Speaker B: Okay, so that's an awful lot to unpack there.
So just kind of continuing with the micronutrient component.
Do these patients, can they use regular over the counter supplements? Do you recommend the bariatric supplements for patients on GLP1s?
How do you approach that? Is it a multivitamin? Is it just specific, you know, B12, vitamin D, calcium, those things? How do you approach that?
[00:10:28] Speaker C: Well, it really depends on that individual and what is in their diet. What is that composition of the diet, did they start with some baseline types of micronutrient deficiencies? If they started with some baseline deficiencies, then of course you want to target those with a specific vitamin or mineral.
For the individuals that just have a lack of appetite, again, it goes back to the history.
Are they a bariatric surgical patient that might have had some weight regain, and now we want to address that with a GLP1 therapy. Those individuals, we need to know a little bit more about the type of surgery they had and they might require that bariatric vitamin specifically.
However, for the general individual that's doing okay just eating a lower caloric intake, around 1200 calories, let's say a high quality multivitamin mineral supplement should be sufficient to meet those needs.
[00:11:38] Speaker B: Okay, well, that's good.
With respect to protein targets, what, what do you recommend for patients on GLP1s and what kind of strategies do you offer them to realistically meet those go goals when their appetite is suppressed?
[00:11:54] Speaker C: Sure.
There's a couple of different methods to meet protein goals and to determine what those protein goals can definitely be a challenge. We see in the literature now a number of papers are coming out and promoting 1.2 to 1.6 grams of kilo per kilogram per day during that active weight reduction. However, if we use the current individual's weight, we can overestimate how much protein that individual should be consuming.
My perspective as a clinician, I prefer to use a range of grams. For example, a target range between 80 to 120 grams of protein seems to work well for most individuals that happen to be on an active weight reduction.
Also, I think it's realistic to use percentages. For example, a high protein caloric diet would be somewhere between 25 to 30% protein intake in the total caloric intake.
This gives the patient a little bit more flexibility.
We eat differently every day.
And I think also it's just kind of a good rule of thumb to work with generalizations and not a specific grams per day with these individuals that are are trying to meet a whole variety of different recommendations that we're making for them.
Strategies.
[00:13:40] Speaker B: I was just going to say that I'd like to use that 80 to 120 range as well.
And I usually typically, you know, adjust the range according to the to the size of the individual. Right. So for a larger individual, it might be closer to 120. For a smaller individual, maybe closer to 80.
[00:14:00] Speaker C: You're absolutely right. Yep, you're absolutely right. And then targeting, you know, low volume and complete proteins that have all the Amino acids, the types of protein sources, the fish, the eggs, dairy products, lean poultry, and red meat. So I think that focus pretty much covers the protein targets, how much we need and utilizing a high quality protein in the diet.
[00:14:29] Speaker B: How about distribution of that protein throughout the day?
I mean, some patients just like to eat one meal.
Does that make sense if you're trying to get to those levels of protein intake?
[00:14:41] Speaker C: Well, that would be kind of tough.
[00:14:43] Speaker B: Yeah.
[00:14:44] Speaker C: Better to distribute eating smaller portions throughout the day, usually starting with a breakfast. Having a structured eating pattern is really important for these individuals. Maybe they have to set a timer to remind them to eat. But you know, 20 to 30 grams at an eating episode would be kind of something a target range. And eating protein probably three or four times throughout the day would make it more realistic for an individual on a lower caloric intake.
[00:15:19] Speaker B: Does the bioavailability matter as well? Or is the bioavailability affected by portion size? Whereas when you get to larger portions or is it less bioavailable than small, frequent portions?
[00:15:34] Speaker C: I would say that bioavailability is better in a little larger amount of protein at a, in a sitting. But I kind of think of bioavailability. What else are they consuming in that mixed diet?
Is there fiber? You know, are there other components within the protein source? Maybe it's a plant protein that may not be as high a quality. I think the digestibility and the bioavailability can all be factors. And when we're talking about protein synthesis and metabolism.
[00:16:12] Speaker B: Okay, and then you talk about bone health and to me I see a double whammy there. If you're developing some sarcopenia and at the same time you potentially have some decrease in bone density, that's really increasing your risk of falls and fractures from falls. Because the loss of muscle strength becomes a big concern about protecting yourself from a fall.
[00:16:43] Speaker C: Absolutely, yes. So we need to think about screening those individuals before adding another type of therapy that might inhibit or add more concerns regarding their bone health, diminishing that bone mineral density.
[00:17:06] Speaker B: And I talked about our muscle mass that was measured by bioimpedance, which is, is an estimation.
But the other thing we worry about is functionality and, and muscle strength. And muscle may change in size, but we really, what we're more concerned is about changes in strength.
[00:17:28] Speaker C: Correct. And that's the quality of muscle with that is associated with the function of. I have used mostly DEXA imaging in my past and my research has been in that. So I have, you know, all of these different mechanisms of how we measure fat free mass.
Muscle mass, those kinds of things, they vary between the different types of methodologies. So whatever you become familiar with, you want to make sure you know, what are those prediction equations that that type of instrument might be using and how do you apply that to the individual? The reason I appreciate using DEXA imaging, now I'm getting a little more information about the bone mineral content as well the bone mineral density.
So that seems to pair well in how I've worked through those types of body composition things with bariatric surgery patients,
[00:18:38] Speaker B: do you look at any measures of strength like grip strength or time to up and go and those things?
[00:18:46] Speaker C: Yep. The functional. Yep. Those functional tests are very important.
Besides just having objective data, you also need to do those functional types of testing within that clinic setting in order to come up with an actual diagnosis of sarcopenic obesity. It takes a couple of different measures to actually document that diagnosis.
[00:19:12] Speaker B: Another thing that you mentioned that I find interesting is the change in taste that patients have when they take these medications.
Sometimes they crave healthier foods and have aversion to sweets. I've even had some people have a sudden craving for sweets that they didn't have before.
So just a really significant change in taste.
How do you address that or assess that and address it?
[00:19:39] Speaker C: Oh, yes, and we've seen this very strong within the bariatric surgery literature. Individuals have very different tastes, smells, perceptions, sensory input immediately following surgery. But that tends to get better with time.
So if the smells are very strong, have somebody else do the cooking or pick foods that do not have strong smells. Also, the same way with the taste sensories, you may need to change your food choices during that interim until you can gravitate more towards foods that might be appetizing to that individual. So it's very individual based and to predict how somebody's going to respond is very difficult. But that's why that baseline education, understanding all these things that might occur when an individual is put on these medications just helps that individual adapt their eating later on if they have some of these concerns.
[00:20:54] Speaker B: And one of the things that I mentioned in the prelude to this was that the patient was thinking about food all the time. And there's a popular term that's being used now called food noise, where patients are seeing changes in how much and how often they think about food. I had a patient the other day say to me, I can't believe how much time I have to think about other things now that I'm not thinking about food all the time.
I was wondering if that's something you noticed with these patients. And do you see that in the bariatric surgery patients as well?
[00:21:31] Speaker C: I've seen it more with the medications than I have in the bariatric surgery population. But I think screening for that food noises is critical. And there's some excellent questionnaires that are out, but that is also kind of taken away, that food noise. And you're spot on with your comments that it kind of opens up this whole world where patients aren't just focused on what am I going to eat next? And always thinking about food. So it's a huge help to these patients. And I think that's a real plus with using the medication for them.
[00:22:12] Speaker B: It is really very relieving for them. And really, most patients don't realize how much they thought about food until they stop thinking about it so much.
[00:22:21] Speaker C: Right, right. It's a quality of life improvement for them.
[00:22:26] Speaker B: So another thing that you mentioned was eating disorders and that we have to be concerned about the eating disorders in patients. And could we be resurrecting some sort of disordered eating behaviors with initiation of these therapies? How do you approach that in the patients that you see?
[00:22:46] Speaker C: I think that really starts with very good screening and using a behavioral specialist psychologist to help and add information to that nutrition assessment.
So if we can target any type of eating, disordered eating behaviors before we start treatment, that's going to help us navigate through the process.
Close monitoring, close tracking, looking at those diet records, I know tracking calories and portions are out, that's not something we want to do anymore. But we can certainly look at eating patterns and the types of things, the frequency of eating, to see how that individual is doing moving forward on treatment.
[00:23:43] Speaker B: Yes. And you know, one of the things that it, that I talk to patients about is developing a different relationship with food that we often eat because we're hungry or we're avoiding eating because we don't want to, we want to restrict our calories. But really kind of shifting their thinking about looking at food as a source of fuel and a source of energy for their body and that they need to refuel their body periodically.
And it's just kind of a different context that I find sometimes helpful for patients to think of it as fueling their body rather than eating or feeding, where there's so much kind of background and so much past issues around that. Whereas if you're thinking it just in the terms of fueling your body, it's a different perspective.
[00:24:33] Speaker C: Absolutely. That's a great analogy. And yes, I have certainly used that in my practice as well, putting that whole concept of how we think about food into a different and a different texture per se, or different context per se.
It's just energy, not the main focus.
[00:24:53] Speaker B: Yeah, right, right.
And then it changes the, the. The need to, to fuel your body. Right. It creates a different perspective on why you're eating.
All right, well, that's a lot of interesting topics here today and I appreciate you sharing them with us. I look forward to your talk at the Obesity Medicine Conference coming up and like to thank you for being with us today. You've made a lot of great contributions to the OMA and thank you for that.
[00:25:27] Speaker C: Welcome.
[00:25:28] Speaker B: All right, well, I'd like to thank everybody for joining us today. If you like this podcast, please share it with a friend and help the OMA as we strive to advance clinician understanding of the disease of obesity.
[00:25:43] Speaker A: Thank you for listening to this episode of Obesity a Disease. For more information about obesity medicine, podcasts and other valuable resources from the clinical leaders in obesity Medicine, please visit www. Obesitymedicine.org podcasts. If you enjoyed this episode and want to listen regularly, head over to itunes where you can subscribe, rate and leave us a much appreciated review. The views expressed in this episode are those of the host and guest and do not necessarily represent the opinions, beliefs or policies of the Obesity Medicine association or its members. Please join us again for our next episode of Obesity A Disease.
