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The topic of weight-loss drugs (aka anti-obesity medications, or AOMs) can be a touchy one for many people in the health and fitness industry. The initial response of some health coaches and exercise professionals has been based on a feeling that people are achieving weight loss in the “wrong way” or rooted in a fear that they—the professionals—may someday be viewed as obsolete.
That is certainly an understandable response. After all, we’ve been preaching about the value of lifestyle change, physical activity and healthy eating for decades while telling clients there is no magic bullet for weight loss and along come these medications that enable some people to achieve their weight-loss goals. And, as stated by Greg Degnan, MD, medical consultant for the Atlantic Coast Athletic Clubs and associate clinical professor of orthopedic surgery at the University of Virginia, “These are effective drugs for weight loss, no question.”
So, where does that leave us? The emergence of drugs like Ozempic, Wegovy and Mounjaro unquestionably marks a significant shift in how people will address overweight or obesity moving forward. How do you as an individual professional, and we as a collective industry, respond to this dramatic change in the landscape of health and wellness?
These drugs, and others like them, are classified as glucagon-like peptide-1 (GLP-1) receptor agonists. For the sake of simplicity, in this article they are referred to collectively as “GLP-1 drugs” or “GLP-1 medications.” These medications have been approved for the treatment of type 2 diabetes, as well as for patients who meet certain criteria, including a body mass index (BMI) of >30 kg/m2, or a BMI of 27 to 29.9 kg/m2 with weight-related comorbidities, who have not met weight-loss goals with comprehensive lifestyle intervention alone. And, while GLP-1 drugs have been applauded for their effectiveness in achieving weight loss in clinical trials, they also introduce new considerations for exercise professionals and health coaches.
It is worth noting that, regardless of the endless discussions taking place in the media and elsewhere regarding these weight-loss medications, your role is not to judge or stigmatize the choices made by your clients, but to coach or train each client with unwavering acceptance. After all, the decision to begin taking any medication, including anti-obesity medications, is best made in collaboration with their physician. Telling a client that they don’t need these drugs because you can help them achieve their weight-loss goals is inappropriate and unprofessional, and will likely drive clients away rather than drawing them in.
Your role is to be open-minded, well-informed and supportive. “This is the first major development in pharmacological treatment of people with obesity we have seen in a long time,” explains Dominique Adair, MS, RD, CLS, Head of Clinical Quality at Nourish. “[These medications] will be game changers for some people. Think of a comparison to other drugs. Given the co-morbidities associated with obesity, we should consider the medical model. We would not fault someone taking a medication for hypertension or diabetes. We should not pass judgement on people with obesity for considering adjunctive drug therapy.”
It’s important to highlight that health coaches and exercise professionals do not play a role in advising clients on whether or not to start taking GLP-1 medications, so the focus of this article is on the role that you can play in encouraging individuals who may be considering them to get qualified advice and supporting those who are taking these drugs while staying within your scope of practice. More specifically, the goals of this article are as follows:
These drugs are not new (see sidebar) and are well studied, so it’s important that you are prepared to work with clients who are taking them. In fact, it’s been forecasted that 7% of Americans (or 24 million people) will be taking GLP-1 medications by 2035.
If clients ask you about whether they should be taking these drugs, which some undoubtedly will, “the first thing to understand,” says Chris Gagliardi, MS, ACE Scientific Education Content Manager, “is that you should not be the person saying yes or no, as offering this type of advice falls outside your scope of practice.” What Gagliardi is referring to is that you can respond to this question as you would any question that falls outside your defined scope of practice—by using your coaching skills or the ACE Mover Method™ to empower them to answer that question for themselves by seeking qualified counsel. You might even help them set goals around talking to their doctor or doing some investigating on their own.
Consider a scenario where an individual who has lost a substantial amount of weight on GLP-1 medications asks why they should continue working with you if they’re already hitting their weight-loss goals. This is where Renee Rogers, PhD, FACSM, senior scientist of physical activity and weight management at the University of Kansas Medical Center, sees a tremendous opportunity for the health and fitness industry.
Dr. Rogers, who is a coauthor of a peer-reviewed article entitled Physical Activity in the New Era of Antiobesity Medications, explains that while we all know the countless benefits of exercise and physical activity, the industry has gotten caught up in the societal wave of weight loss as the primary reason to move. As more people begin losing weight on these drugs, we can bring more attention to the other benefits of physical activity, from reduced symptoms of depression and enhanced mood to improved cardiovascular health and better physical function. Be sure to check out the ACE Mover Method dialogue at the end of this article that addresses this scenario, written by Gagliardi, who also holds all four ACE Certifications.
Dr. Rogers encourages us to think about how meaningful those conversations can be when they are personalized and the stigma of weight is removed. Instead of clients feeling like they have to do something to burn more calories, whether that’s walk a specific number of steps or do a certain number of minutes of exercise to meet the recommendations for weight loss, they can become more attuned with what they value, cherish and enjoy about physical activity.
Another potential benefit: GLP-1 drugs may remove a barrier for participation in physical activity for many people. Many people with obesity cite physical pain, the emotional and psychological discomfort they feel in the gym, and issues with not feeling physically able to use certain machines or types of equipment due to their size as reasons why they aren’t physically active. These drugs may enable some people to lose weight and overcome these barriers. This can be life-changing for numerous reasons, explains Gagliardi, so it’s essential that you avoid minimizing the potential impact these medications may have on people’s lives and on public health.
The mechanisms by which GLP-1 drugs drive weight loss include reducing appetite and slowing gastric emptying. While effective for weight loss, these two mechanisms may lead to a handful of side effects that may impact some people’s ability to exercise and eat well. Reported side effects include fatigue, a feeling of being overly full and overall weakness. It’s important to note that, like all drugs, side effects vary widely from one person to the next and, for many people, diminish over time, so there is no single approach that will work for every client.
Again, this is an opportunity to use your coaching skills to talk to clients about what they are experiencing, with an understanding that it could change from day to day. As part of that conversation, be sure to inquire about any medication or dosage changes, which can impact how they’re feeling in a way that may require you to modify your planned workout. As you would with any client, be sure to take inventory of how they feel before each session and adjust their workout accordingly.
One of the primary concerns your clients may be reading or hearing about is the potential loss of lean mass associated with taking GLP-1 medications. The concern is that people may be losing more lean mass when dropping weight as a result of taking these drugs than they might if they achieved the weight loss through diet and exercise.
“It’s important that we’re honest about this concept right now based upon where the research is and what we know,” explains Dr. Rogers. “We are at the very early stages of understanding what’s really happening with lean mass on these medications.”
However, she also notes that any time someone loses weight, they are going to lose lean mass, and this may be especially true if they lose that weight rapidly. If a person is carrying extra weight around for a long time, they are going to need extra muscle mass to hold up that frame and support it. As they lose fat, less muscle is needed to support the body’s overall mass. In addition, Dr. Rogers points out that if a person achieves weight loss without performing physical activity, particularly muscular training, they are going to lose more lean mass—and that holds true whether the weight is lost via GLP-1 medications or dieting.
So, what does this all mean to your daily practice as a health coach or exercise professional? Most importantly, muscular training must be an element of these clients’ ongoing exercise regimen. As Gagliardi highlights, twice-a-week muscular training is already included in the Physical Activity Guidelines for all adults, and being on these medications doesn’t change that. While you ought to be encouraging all your clients to meet that goal, you might want to emphasize its importance to clients taking GLP-1 drugs, particularly if they are newcomers to the gym setting.
In addition, Gagliardi suggests incorporating ways to measure and track body composition, along with muscular strength and other functional assessments. Dr. Degnan, who is a member of the ACE Scientific Advisory Panel, also underscores the importance of tracking body composition. It is widely accepted that taking these medications is not a short-term fix, as people need to keep taking the drugs so as not to regain the weight they have lost. Therefore, it’s vital that you empower your clients with the knowledge they need and help support them as they set and pursue muscular-training goals.
One final tip from Dr. Rogers: Avoid claiming that muscular training will completely attenuate the loss of muscle mass that clients are likely to experience, as we simply don’t yet have the evidence to back up that statement. This is another area where language matters and you don’t want to mislead your clients. Instead, highlight how muscular training will help counter some of the side effects of these drugs, especially fatigue.
Nutrition is a primary consideration to keep in mind when working with clients taking GLP-1 drugs, as it can be challenging for them to meet their nutritional goals (including eating enough protein to maintain muscle mass) and to eat a balanced diet while consuming so few calories. People are simply not hungry when taking these drugs, so eating enough can be a challenge. Additionally, clinical trials have found that consuming more protein than the recommended dietary allowance not only reduces body weight, but also enhances body composition by decreasing fat mass while preserving fat-free mass in both low-calorie and standard-calorie diets. This may be a consideration for clients taking these drugs, as they have such dramatically decreased appetites.
You don’t want to overstate the need for protein, as we don’t yet know how much protein or supplementation is actually needed, says Dr. Rogers. A strategy that Adair, who is also a member of the ACE Scientific Advisory Panel, recommends involves consuming some form of protein with every meal and snack. This helps ensure that the individual doesn’t get behind on their protein intake and have to make up for a deficit, which can be hard to do when appetite hormones have been impacted by anti-obesity medication.
While there are countless strategies and equations available to determine how much protein a person needs to achieve nutritional balance, we really don't yet know the ideal amount for people who are taking these drugs. Instead, Adair recommends that coaches and trainers working with clients taking GLP-1 drugs collaborate with a registered dietitian (RD), if possible, who can both determine energy intake, as well as make sure the foods a client is eating are as nutrient dense as possible. “Think of it as a budget,” urges Adair. “If your budget—the ‘intake’—is drastically reduced, you want to make sure you are getting the most nutrition—or value—from the foods selected.”
An RD can also help monitor individuals for nutrient adequacy or deficiencies, which are a concern whenever caloric intake is dramatically decreased. “The risk for nutrient gaps comes not just from decreased intake but can also come from some of the side effects, nausea and vomiting being the most common,” explains Adair. "Importantly, there are RDs who have been working with people taking GLP-1 medications to treat either diabetes or obesity, so they are particularly experienced at helping clients manage these side effects, protect against nutrient deficiencies and achieve an optimal diet, which is essential for disease prevention, maintaining energy and overall quality of life."
Dr. Rogers offers a few strategies you can share with clients. First, think about self-monitoring, but shift the focus from calorie counting to a nutrient density/quality perspective. Also, urge clients to be mindful of how they feel after eating different foods (overly full, energetic, sluggish, etc.) and use that information to guide future intake. Finally, Dr. Rogers concurs with Adair about the need to collaborate with an RD who can help your clients pursue holistic health.
Never lose sight of the complex interplay between nutrition and exercise, especially considering the effects and side effects of these drugs. A suboptimal diet can have a profound impact on energy levels, while feeling bloated often means people drink less water and struggle to stay hydrated. So, don’t underestimate the challenges these clients face in maintaining healthy and balanced nutritional habits.
It’s also important to recognize that those who are taking GLP-1 medications may have had a rocky history with physical activity and nutrition, characterized by years of yo-yo dieting or extreme tactics to lose weight. They may need supportive behavior-change coaching that makes it possible for them to develop healthy lifestyle habits that address their overall health and well-being—not just their weight. This is the type of support you are ideally positioned to provide as a health and exercise professional.
When asked about what she thinks these drugs mean for health coaches and exercise professionals going forward, Dr. Rogers points to her experience interviewing study participants as part of her qualitative work in this area. What she’s found is that they report believing that exercise is still very important, but they are not confident that it’s going to help them as much as this medication is helping them.
Dr. Rogers sees this as a tremendous opportunity to talk about other reasons to move, beyond weight loss. You can tell your clients, yes, the medications are probably more effective than exercise when it comes to weight loss, but that simply means that we no longer have to talk about exercise only in that context. This may lift a tremendous burden from people who have likely been thinking about, working at, and failing at weight loss for much of their adult lives.
In 2022, the American Gastroenterology Association released evidence-based guidelines that strongly recommend, for the first time, the long-term use of anti-obesity medications for adult patients who haven’t been able to successfully lose weight through lifestyle changes alone. However, as part of those guidelines, concurrent therapeutic lifestyle behavior change (including diet and exercise) is also featured. This offers another opportunity for health coaches and exercise pros, as it means that healthcare professionals will be encouraging their patients to move more and eat a healthier diet while on these drugs. Health coaches and exercise pros are perfectly positioned to seize this opportunity and become the go-to resource for these individuals as they continue on their health and wellness journeys.
“For many people, these drugs will release them from an appetite/satiety system that has not been working for them,” explains Adair. “Patients report things like, ‘For the first time I am not thinking about food and being hungry all day long.’ With this added pharmacological support, health and exercise professionals can use their skills to help the client identify additional goals such as health or mobility that may have been deprioritized because they were so focused for so long on hunger and weight.”
In other words, these medications may help reduce some of that “food noise” and free up time to focus on physical activity as it connects to happiness, quality of life, stress management, sleep quality, etc. When weight loss is no longer the primary goal of exercise (as it has long been for many people), the myriad benefits of movement become more apparent and accessible, which, in turn, may lead to a more well-rounded approach to health and more open and meaningful conversations with clients.
“If we can work with [healthcare practitioners] and work with people taking these medications, I don’t think there’s anything to be scared of,” says Dr. Rogers. “We have a really great, new opportunity in front of us. Why battle with something that is helping people? Let’s partner. It’s about partnering, and that opens the door for us.”
The central message that you, as a health and exercise professional, are well positioned to deliver is that healthy lifestyle habits and behaviors are essential for achieving overall health and wellness—and this is true for everyone. “Any tool that can be used safely and effectively should be used, but it should be used properly and as part of the tool chest,” urges Dr. Degnan. “There is no one solution.”
Your skills as a health coach or exercise professional comprise many of the other needed tools in that proverbial tool chest, so seize this opportunity to help clients achieve goals that extend beyond weight loss into other aspects of their overall health and wellness.
The conversation around GLP-1 medications and their impact on the health and fitness industry is fluid and continuously evolving. ACE will continue to monitor and report on the impact of these drugs, including emerging research, in the future.
You have been working with a client for the past six months. During this time, under the direction of a physician, he has been using an injectable GLP-1 drug in conjunction with a reduced calorie diet and increased physical activity to better manage his weight. For the first time in his adult life, his body mass index has dropped below 30 kg/m2. He is excited about the progress he is making but would like to lose an additional 20 to 30 pounds. At the end of a recent session, he mentioned that he is not sure if he needs to continue to exercise because the drug is giving him the results he is looking for.
Elements of the ACE Mover Method and the ACE ABC ApproachTM can be used with clients who are considering making changes to their existing routine to explore their reasoning and motivation more fully. It is not the role of the health coach or exercise professional to tell the client what they should or should not be doing, but rather to be there with the client acting as a guide throughout the decision-making process. The following example illustrates the proper use of this technique.
Ask: Asking powerful open-ended questions during this conversation can help you to confirm what the client is hoping to achieve by making the desired change.
Exercise Professional: Thank you for sharing with me your thoughts about the need to continue exercising now that you are losing weight with the prescription medication you are using. Tell me more about the decision you are considering.
Client: For as long as I can remember, I have made various attempts to change my diet and to exercise more without ever seeing any long-term success with managing my weight. Now, in the past six months, I have made significant progress in lowering and managing my weight. The way I see things, it is the medication and not the exercise and diet that are making the impact. My doctor told me that I can maximize the benefit of the medication by using it in conjunction with exercise and making healthier food choices, but now that the weight is coming off, I wonder if there is still a need to continue with exercise.
Exercise Professional: You no longer see the value in continuing to exercise to maximize the benefits of the medication.
Client: Well, I still want the maximum benefit from the medication, but I wonder how much of a difference exercise is making.
Exercise Professional: What other reasons might there be for you to continue with exercise?
Client: Weight loss has been my main reason for exercising but I am sure there are other benefits.
Break down barriers: Barriers to behavior change come in many different forms. Sometimes, even our thoughts can be an obstacle to lasting behavior change. In this scenario, the exercise professional uses the ask-offer-ask (AOA) technique to learn more about what the client already knows about the benefits of exercise and to offer additional information, with the client’s permission.
Exercise Professional: (Ask) May I share with you other benefits to exercising beyond weight loss that I think might be of interest to you?
Client: Yes, please.
Exercise Professional: (Offer) Great. Some other benefits include a lower risk of death from any cause, as well of hypertension, type 2 diabetes and an adverse blood lipid profile. In addition, regular exercise can lead to improved cognition, reduced anxiety and depression, improved sleep, and improved muscular and cardiorespiratory fitness. Does that help give you a better idea of how else exercise might be important? (Ask)
Client: Yes. So, even though exercising for weight loss may not be a top priority for me now, there are other reasons why exercising could still be important. Managing my other health conditions is valuable to me and I like the idea of improving my fitness. It seems like even though there are benefits to losing weight, simply weighing less may not necessarily make me more fit or necessarily change the status of my other health conditions.
Exercise Professional: Exactly. You can think in terms of achieving an optimal level of health. Weight loss and management is an important facet, but focusing on all aspects of health can improve your overall quality of life and other health parameters. Does all of this make sense?
Client: It has been helpful to talk through my thoughts and feelings with you. I want to continue with the exercise I have added to my life.
Collaborate: Now that the client has expressed an interest in continuing to exercise, the professional and client can work together to establish the most appropriate next steps.
Exercise Professional: Currently, we are meeting on two days per week to focus on muscular training exercises and you are walking three days per week for a total of 90 minutes each week. How will you move forward today?
Client: I would like to continue to meet with you two days per week and I would like to increase my total walk time each day by 5 minutes. Also, since we have been talking about other ways that exercise can improve my health, will you help me to determine some ways to track my progress on things like muscular and cardiorespiratory fitness?
Exercise Professional: Absolutely! We can collaborate on ways to track your progress to ensure we are using methods that are meaningful to you. I will put together some ideas I think you might like and share them with you during our next session. Please come prepared with some of your own ideas as well. I look forward to continuing our work together and hearing about how increasing your daily walk time by 5 minutes is going for you when we meet for our next session.
The ACE Mover Method and ACE ABC Approach are organized and efficient client-centered ways for exercise professionals to connect with clients on a deeper level, while always remembering that each client is resourceful and capable of change. Adopting the Mover Method philosophy and using the ACE ABC Approach keeps the client in the expert role when it comes to decision making. In this scenario, we explored a situation that may become more commonplace in the health and fitness industry soon. It is not the role of the exercise professional or health coach to become an expert in GLP-1 drugs, but it is important to use the skills described above to partner with clients to help them make their own informed decisions.
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