The rapid adoption of GLP-1 receptor agonists has fundamentally altered obesity management, with these medications now prescribed to millions of patients seeking significant weight loss. Yet a substantial number of physicians continue to prioritize lifestyle interventions as their primary approach, even as professional guidelines increasingly emphasize pharmacologic options and patients arrive with specific medication requests.
What drives this clinical philosophy in an era where injectable medications promise double-digit weight loss? The answer lies not in resistance to innovation but in a nuanced understanding of what produces lasting results in real-world practice.
Guidelines Support Combination Therapy, Not Medication Replacement
Current medical guidance reflects the growing evidence base for antiobesity medications while maintaining emphasis on behavioral foundations. As noted in the National Institutes of Health’s Endotext chapter on obesity pharmacotherapy, current guidelines recommend that individuals who have attempted lifestyle improvements and continue to have a BMI of ≥ 30 or ≥ 27 with an obesity-related comorbidity may be eligible for weight-loss medication treatment.
The guidance emphasizes that antiobesity medications “are indicated in combination with lifestyle modification for the management of overweight and obesity,” similar to approaches used for other chronic diseases.
These guidelines represent a significant evolution from previous recommendations that positioned medications as last-resort options. However, they consistently emphasize pharmacotherapy as an adjunct to, rather than a replacement for, structured behavioral interventions. This distinction proves crucial for physicians who maintain lifestyle-first approaches. They’re not ignoring current guidance but interpreting it through the lens of clinical experience and patient outcomes.
Real-World Data Reinforces Lifestyle Foundations
Real-world outcomes highlight the limitations of medication without sustained adherence. This may help explain why some clinicians continue to lead with lifestyle interventions.
A Cleveland Clinic study of 7881 patients with obesity published in the journal Obesity revealed significant gaps between clinical trial efficacy and everyday practice outcomes. More than 50% of patients discontinued GLP-1 medications within 1 year — 20% within 3 months and 32% between 3 and 12 months. Additionally, more than 80% remained on subtherapeutic maintenance dosages.
The weight-loss results varied dramatically based on adherence and dosing. Patients who discontinued early achieved only 3.6% weight loss, while those who discontinued late lost 6.8%. Patients who continued treatment lost 11.9% on average, but those who both continued treatment and achieved high maintenance dosing lost 13.7% with semaglutide and 18.0% with tirzepatide — results approaching clinical trial outcomes.
Dexter Shurney, MD, MPH, MBA, chief medical officer at ModifyHealth, sees these data as validation of his approach: “The majority of common chronic conditions — hypertension, [congestive heart failure] 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.”
Clinical Philosophy Rooted in Sustainability
For physicians committed to lifestyle-first care, the approach stems from observed patient outcomes rather than theoretical preferences. Kenji Kaye, MD, a board-certified internist and concierge physician with South Denver Concierge 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.”
This perspective is informed by understanding obesity as a multifactorial condition requiring comprehensive intervention. As Kaye notes: “Lifestyle habits, genetics, hormonal state, activity level, and other comorbid conditions all contribute to obesity. I like to focus on addressing the variables that will have the biggest impact while evaluating for underlying contributing medical conditions.”
The sustainability argument extends beyond weight loss to broader health outcomes. Shurney emphasizes the systemic benefits of lifestyle interventions: “Lifestyle medicine has a much broader clinical application than a single medication or surgical intervention, which are typically designed to treat one condition at a time and come with multiple side effects. Lifestyle interventions work well to effectively avoid the polypharmacy issues that many patients often face.”
He cites dramatic results achievable with intensive lifestyle programs: “When starting a patient on a rigorous lifestyle medicine program for type 2 diabetes, it is often necessary to reduce their insulin dose by half within days to avoid hypoglycemia. I have routinely seen average drops in cholesterol of 20%-50% within 7-8 weeks.”
Strategic Medication Use Within Lifestyle Framework
Even among physicians who lead with lifestyle-based care, some incorporate GLP-1 receptor agonists as part of a broader treatment plan that includes behavior change. Elizabeth Slauter, MD, a board-certified family medicine and obesity medicine physician who practices at a direct primary care clinic in Boerne, Texas, explains her approach: “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.”
The decision to add medications often hinges on practical considerations. Cost remains a significant barrier, with many patients unable to afford long-term treatment. Slauter frequently encounters this challenge: “Many people cannot afford the cost of medications, especially long term — and research shows that these medications are often needed long-term to maintain results,” she said.
Insurance coverage inconsistencies and prior authorization requirements create additional barriers. The Cleveland Clinic study identified cost and insurance coverage as primary reasons for treatment discontinuation, alongside side effects and medication shortages.
For these physicians, medications serve as tools within a comprehensive framework rather than standalone solutions. Kaye describes his typical process: “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 and Media Influence
The widespread media coverage of GLP-1 receptor agonists has created new clinical challenges. Patients increasingly present with specific medication requests, often based on social media testimonials or celebrity endorsements rather than clinical assessments.
Kaye addresses this directly: “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.”
Setting realistic expectations becomes crucial, Slauter said. “One issue I run into frequently is that patients expect to be on weight-loss medication for a short term, and this is not always reasonable,” she said. This expectation management is particularly important given the Cleveland Clinic data showing that discontinuation leads to reduced effectiveness.
The educational approach allows physicians to address misconceptions while maintaining therapeutic relationships, Kaye said. “Most of the time patients welcome an open discourse about options and strategies to achieve their goals,” he said.
Systemic Pressures and Professional Conviction
Healthcare systems increasingly favor interventions that produce rapid, measurable outcomes, creating pressure to prescribe medications over time-intensive lifestyle counseling. Reimbursement structures often inadequately compensate for the extended counseling sessions required for effective lifestyle interventions.
Shurney identifies this as a fundamental barrier: “The lack of reimbursement parity for lifestyle interventions is a disincentive to practice this way,” he said. “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.”
Some physicians have modified their practice models to maintain their clinical philosophy. “I joined a direct primary care specifically to have the time to counsel my patients on this,” Slauter said. “A traditional insurance-based practice did not offer the time needed for this.”
Long-Term Perspective Drives Clinical Decisions
What ultimately sustains these physicians’ commitment to lifestyle-first care is their long-term perspective on patient outcomes, Kaye said. “After seeing many patients start down the pathway of pharmaceuticals and ultimately not reaching their goals reaffirmed my commitment to a more holistic approach,” he said. “In my experience, without a strong foundation of lifestyle changes, the long-term success rate is low even with antiobesity medications.”
This perspective is reinforced by concerns about healthcare sustainability. Shurney warns: “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.”