Every new GLP-1 seems to promise a higher quantity of weight loss for adults with obesity, with the message of more pounds lost, more success.

Tirzepatide (Zepbound) produced a 22.5% average reduction at 72 weeks, with the Obesity Medicine Association citing the SURMOUNT-1 trial and saying it stands out as “the most effective FDA-approved prescription medication for weigh loss.”

On its heels, however, are other medications, including retatrutide, the triple agonist medication activating receptors for GLP-1, glucose-dependent insulinotropic polypeptide and glucagon, which produced up to a 30% weight loss when taken for 104 weeks.

The “percent lost” competition may be good for pharmaceutical companies’ bottom lines, but the focus on pounds lost alone must shift, growing numbers of obesity experts and researchers caution. It’s crucial to consider weight-loss quality, not just quantity, for overall health.

Even some physicians are still locked into the focus on quantity, Robert Dubin, MD, associate professor at the Pennington Biomedical Research Center, Louisiana State University in Baton Rouge, Louisiana, told Medscape Medical News.

Changing that, he said, requires a mindset shift, which he and many of his colleagues have already adopted.

“We have always taken the approach that ‘We are going to focus on your health, not just your weight,’” he said. Easier said than done, as he knows, as patients can be very strongly focused on pounds lost as the only barometer of success. For many, he said, “It’s an ingrained concept.”

The arrival of incretin drugs and their impressive weight-loss results has ramped up the concerns about the quality of weight loss, according to Pam Brown, general practitioner in Swansea, Wales, who has written extensively on the topic. She is also program development lead for obesity and weight management at iHeed/University of Warwick in Coventry, England, and editor-in-chief of Diabetes Distsilled.

“Since incretin drugs have been widely used and demonstrated to support significant weight loss, experts have raised concerns about the quality of weight loss, and loss of fat free mass such as bone and muscle,” Brown said in an email interview with Medscape Medical News.

The goal is to optimize fat loss and preserve muscle. However, there is an ongoing debate about how concerning the muscle mass loss with GLP-1 use is.

Quality Conversation Is Growing

Debate aside, the topic of weight-loss quality surfaces often in medical literature, both in research studies and commentaries.

One recent report talks about high-quality weight loss in obesity, defining it as a high proportion of fat to skeletal muscle mass lost.

Another calls the balance between weight-loss quantity and quality the Goldilocks concept for chronic weight management.

Yet another report, “Not All Weight Loss is Equal,” discusses investigational muscle-preserving therapies used with GLP-1s, noting that 25%-40% of total weight loss with GLP-1s may reflect skeletal muscle mass loss or other fat-free mass, according to some reports.

Some pharmaceutical companies are entering the discussion. Novo Nordisk, maker of the GLP-1s liraglutide (Saxenda) and semaglutide (Wegovy), posted an educational piece for patients, “Quality over quantity: A smarter way to lose weight.”

Bringing Quality Into the Conversation

Medscape Medical News asked four obesity specialists if and how they address the quality issue in conversations with patients trying to lose weight. They do.

“I agree there is too much focus on the number on the scale,” said Michael Weintraub, MD, clinical assistant professor of medicine at NYU Langone, New York City. He educates patients about how the weight gain has affected their metabolic and physical health — and how losing it improves their health.

He asks patients to consider: How is your weight affecting your blood sugar, your risk for cardiovascular disease, and your cholesterol numbers?

“Those are the things that matter,” he told them. “The BMI or the number on the scale is lower on the list of what I focus on. When I talk about it in this way, people understand.”

It must be an ongoing conversation, Weintraub said. Every time he sees a patient, he suggests looking at improvements that have happened with the weight loss, such as how their blood sugar has improved — or how they may have been able to stop antihypertensive medications.

Focusing solely on weight increases the stigma, and patients with obesity already encounter that, Dubin said. It is possible, he said, to focus from the start on the health benefits of weight loss — and get patients on board with the quality and quantity approach.

“I had a patient this week who was thinking about [starting] a GLP-1,” he said. The patient had diabetes and a BMI of about 80. During a 1-hour consult, Dubin did not talk about weight, BMI, or pounds she needed to lose. “I focused on health, diabetes, her quality of life.” They talked about how the medications could bring her AIc, currently at 9%, < 7%, which was, he told her, “where it needed to be.”

The reaction? She was all in favor.

That conversation, he said, was much more productive than telling her she needed to lose over 100 lb.

“Of course we want to see the weight loss in pounds,” said Sany Thomas, MD, a bariatric surgeon and minimally invasive surgeon who is director of the adolescent bariatric surgery program and the obesity medicine program at Denver Health. But she focusses on how that weight loss helps them feel — and be — healthier. “It has to be part of our narrative from the start.”

“Congrats, you’ve lost 5 lb,” she might tell a patient. “But how do you feel in your body?” She points to benefits when they occur, such as less need for medication, or no longer needing insulin. “That is an area for celebration,” she told patients.

She addresses expectations as most patients are very familiar with the promises of 20% or higher weight loss. She reminds them: “Clinical trials are not real life.” She cautions them that they may only get a 10% loss — but that also comes with health benefits.

“Anytime you lose weight you are going to lose muscle,” Michelle Gordon, DO, a direct-pay obesity medicine specialist in Westchester, New York, told her patients losing weight —whether on a GLP-1 or other approach. With a GLP-1, she said, it’s likely to be more muscle loss.

She stresses the need for strength training — 20 minutes twice a week if a patient is able — and adequate protein intake, which varies from person to person.

She evaluates body composition regularly and that helps convince patients the weight-loss goal isn’t just about the number on the scale.

Weight Loss Quality Targets

Researchers calling the balance between quality and quantity as the “Goldilocks” for chronic weight management suggest 12 weight quality targets, including reducing fat mass, doing so with minimal impact on lean mass, minimal bone loss, preserving insulin sensitivity and energy expenditure, resetting the satiety set point, improved quality of life, increased mobility, pain reduction, remission or prevention of comorbidities, minimizing need for other drugs, and sustainability over time.

In a recent report, Brown reviewed that paper and distilled the targets to a few practice points:

• Prioritize quality outcomes when talking about weight management options.
• Communicate the concept of weight-loss quality.
• Promote physical activity as key in optimizing weight-loss quality and minimizing weight regain.
• Support patients with guidance on lifestyle as well as on the medications.

Dubin and Thomas reported having no relevant disclosures. Brown reported receiving funding from Novo Nordisk, Lilly, Boehringer Ingelheim, and Abbot for delivering education over the past few years. She reported that her role as editor-in-chief of Diabetes Distilled being funded by OmniMed, an education and conference company. Gordon reported owning shares in Eli Lilly and Viking Therapeutics.