The rise of GLP-1 receptor agonists such as semaglutide and tirzepatide has transformed obesity management. Millions of patients now use these injectable drugs in pursuit of significant weight loss, and professional guidelines increasingly emphasize pharmacologic treatment. Yet, despite the promise of double-digit weight loss, many physicians still start with lifestyle interventions — nutrition, physical activity, and behavioral support — as the foundation of care.
At first glance, this may seem like resistance to innovation. In reality, it reflects a deeper philosophy shaped by evidence, clinical experience, and a long-term view of health outcomes.
Guidelines emphasize combination, not replacement
Current clinical guidance supports the use of weight-loss medications for adults with a BMI ≥ 30, or ≥ 27 with obesity-related conditions, provided that lifestyle changes alone haven’t been sufficient. Importantly, guidelines recommend combining pharmacotherapy with behavioral strategies rather than using medication as a standalone solution.
This shift from “last-resort” use of medication to a more proactive tool marks progress in obesity care. Still, the emphasis on adjunctive therapy reassures physicians who keep lifestyle-first approaches at the center of their practice. They aren’t ignoring guidance — they’re interpreting it through the lens of long-term sustainability.
Real-world data underscore the challenge
Clinical trials show dramatic results with GLP-1s, but real-world adherence is a major hurdle. A Cleveland Clinic study of 7,881 patients highlighted this gap:
- 50% stopped GLP-1 treatment within one year.
- 20% discontinued within three months.
- More than 80% remained on subtherapeutic doses.
Weight-loss outcomes reflected these patterns:
- Early discontinuers lost only 3.6% of body weight.
- Patients who stayed on treatment lost 11.9% on average.
- Those who reached full therapeutic doses achieved up to 18% loss, approaching clinical trial results.
For physicians like Dexter Shurney, MD, MPH, MBA, these findings validate a lifestyle-first model:
The majority of common chronic conditions — hypertension, CHF, hyperlipidemia, diabetes, depression, and obesity — are fundamentally lifestyle issues. Therefore, a lifestyle-first approach to care makes perfect sense because it addresses root cause.
Why lifestyle remains the foundation
Many clinicians see firsthand that without lifestyle changes, even the most effective drugs or surgeries can fail. Kenji Kaye, MD, an internist in Denver, explains:
Without foundational lifestyle changes, medications and surgery are destined to fail. We have seen many patients not lose weight or even gain weight despite max dosages of these pharmaceuticals.
Physicians stress that obesity is a multifactorial condition, shaped by diet, activity, genetics, hormones, and comorbidities. Addressing only one piece of the puzzle rarely yields durable results.
Dr. Shurney highlights another benefit: Lifestyle medicine reduces polypharmacy risk. Unlike single-condition drugs, lifestyle interventions improve multiple markers simultaneously — cholesterol, blood pressure, insulin resistance, and mental health.
In fact, intensive programs can yield rapid systemic improvements: Insulin doses cut in half within days for type 2 diabetes patients, plus 20–50% cholesterol reductions within two months.
Medications as strategic tools
Even physicians who prioritize behavior change often incorporate GLP-1s selectively. Elizabeth Slauter, MD, an obesity medicine physician in Texas, says:
Studies consistently show that the best outcomes with obesity medications occur when they are combined with lifestyle changes. So, it makes sense to start with lifestyle interventions as a foundational approach.
Barriers like high costs, inconsistent insurance coverage, and frequent shortages make long-term GLP-1 use impractical for many patients. For this reason, physicians frame medications as tools within a broader treatment plan, not as standalone solutions. As Dr. Kaye explains:
My usual practice is to discuss these medications as an option but only after a careful review of their food choices, activity level, health history, and current medications.
Navigating patient expectations
The popularity of GLP-1s in the media has created new dynamics in the exam room. Patients often request them directly, influenced by celebrity endorsements and online testimonials. Dr. Kaye sees this as an opportunity for education:
Medications like GLP-1s are mentioned almost everywhere including the media, pharmaceutical ads, and celebrity gossip. When a patient presents asking for a prescription, it is a perfect opportunity to really delve into the details of what these medications can offer and also the risks involved.
Expectation-setting is critical. Many patients assume they’ll only need medication short-term, but research shows discontinuation usually leads to weight regain. Helping patients understand the realities of long-term therapy protects both outcomes and trust.
System pressures and practice choices
Healthcare systems often incentivize quick, measurable results. Writing a prescription is more easily rewarded than time-intensive counseling sessions. Dr. Shurney explains:
The lack of reimbursement parity for lifestyle interventions is a disincentive to practice this way. It’s much easier to prescribe a medication and receive the “quality prize” for checking the drug adherence box than to prescribe lifestyle and not receive a similar financial reward.
To counter this, some physicians have shifted to direct primary care models, which allow longer appointments and more patient-centered counseling.
The long-term view
Ultimately, physicians who remain committed to lifestyle-first approaches are guided by long-term outcomes and healthcare sustainability. Dr. Kaye reflects:
After seeing many patients start down the pathway of pharmaceuticals and ultimately not reaching their goals reaffirmed my commitment to a more holistic approach. In my experience, without a strong foundation of lifestyle changes, the long-term success rate is low even with antiobesity medications.
Dr. Shurney adds a cautionary note:
What we risk are ever-higher healthcare costs, since these medications are very expensive and need to be taken for years, if not forever, to sustain the weight loss. Additionally, we still do not know the long-term effects of these medications.
Your responses and feedback are welcome!
Source: “Why Some Physicians Still Lead With Lifestyle-First Obesity Care Despite the GLP-1 Revolution,” Medscape, 8/12/25
Source: “Pharmacologic Treatment of Overweight and Obesity in Adults,” NIH.com, 8/20/24
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