Response to the Letter to the Editor by Bett et al.

TO THE EDITOR: We thank Bett and colleagues for their interest in our review, “Nutritional considerations with antiobesity medications” [(1)], and we appreciate the opportunity to respond to their letter.

Because obesity is a chronic disease, we recognize the importance of long-term data on outcomes of treatment with any antiobesity medication (AOM). A significant body of evidence from randomized controlled trials has supported the efficacy and safety of Food and Drug Administration (FDA)-approved AOMs for chronic weight management, including liraglutide (2014), semaglutide (2021), and tirzepatide (2023). Examples of completed randomized controlled trials of >1 year duration include, but are not limited to, the SCALE trial of liraglutide (NCT01272219; 160 weeks) [(2)], the SELECT trial of semaglutide (NCT03574597; 208 weeks) [(3)], and the SURMOUNT-4 trial of tirzepatide (NCT04660643; 88 weeks) [(4)]. Ongoing trials (e.g., SURMOUNT-MMO; 260 weeks) will provide additional long-term data to help inform clinical decision-making.

We aimed to present a balanced view of the benefits and potential adverse events (AEs) associated with AOMs, with a focus on common AEs that may impact nutritional status, such as gastrointestinal AEs. We recognize that other AEs, including rare but serious events, can occur during treatment, as has been detailed elsewhere [(5, 6)].

We agree, as noted in the manuscript, that weight regain is commonly seen on treatment cessation and is observed with various obesity treatments, including intensive lifestyle interventions [(7)] and AOMs [(1)]. This highlights the chronic and relapsing nature of the disease and suggests that chronic treatment may be necessary for maintenance of weight reduction. We recognize that limited access to obesity treatment, including but not limited to AOMs, is a major barrier. Challenges that impact access to medications must be addressed to optimize patient care over the long term.

We recognize that energy requirements vary based on many factors, including age, sex, body weight, and physical activity. We noted in our review that goals for energy intake should be personalized. However, we felt it was important to provide general guidance on minimum goals for energy intake during obesity treatment in particular. Our review of current evidence from low-calorie diets, bariatric surgery, and dietary guidelines for adults overwhelmingly presented energy intake guidance based on sex rather than weight. By contrast, when weight reduction is not the goal, as in the inpatient setting, energy prescriptions are often based on weight. Additional research may help clarify optimal energy intake during weight reduction. Our review included recommendations for liquid meal replacements and high-quality protein supplementation as needed. Whey was not specifically recommended, but these products are often whey-based.

We agree that dietary fiber intake without adequate water intake could lead to constipation and noted in our review the importance of attention to both fiber and fluid intake. Our review also highlights the importance of food sources of dietary fiber (“fruits, vegetables, and whole grains”), which contain a mix of soluble and insoluble fiber.

We appreciate the interest in our review. Additional research can help refine future recommendations for optimal dietary intake, including intake of energy, protein, and micronutrients during treatment with AOMs.

Jaime P. Almandoz has received consulting fees from Boehringer Ingelheim, Eli Lilly and Company, and Novo Nordisk A/S; received payment or honoraria for lectures from Clinical Care Options, the Institute for Medical and Nursing Education, and PeerView; and served in a leadership or fiduciary role with The Obesity Society Governing Board. Thomas A. Wadden has received consulting fees from Novo Nordisk A/S and WW International, Inc. (formerly Weight Watchers). Colleen Tewksbury has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the Academy of Nutrition and Dietetics and the Commission on Dietetic Registration; received support for attending meetings and/or travel from the Academy of Nutrition and Dietetics; served in a leadership or fiduciary role for the Academy of Nutrition and Dietetics Weight Management Dietetic Practice Group Executive Committee; and served as a spokesperson for the Academy of Nutrition and Dietetics. Caroline M. Apovian has received institutional grants from GI Dynamics Inc. (now Morphic Medical), Novo Nordisk A/S, and the Patient-Centered Outcomes Research Institute; received consulting fees from Cowen and Company, LLC; received payment or honoraria for lectures from Rhythm Pharmaceuticals, Inc.; participated on advisory boards for Altimmune, CinFina Pharma, Currax Pharmaceuticals, EPG Communication Holdings, Form Health, L-Nutra, NeuroBo Pharmaceuticals, Inc., Novo Nordisk A/S, PainScript, Palatin Technologies, Inc., Pursuit By You, ReShape Lifesciences, Inc., Riverview School, and Roman Health Ventures Inc.; served in a leadership or fiduciary role with the World Obesity Federation; and received stock or stock options from Gelesis and Xeno Biosciences. Angela Fitch has received consulting fees from Eli Lilly and Company, Jenny Craig, Novo Nordisk A/S, Sidekick Health, and Vivus; received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Novo Nordisk A/S; received payment for expert testimony from the state of Massachusetts; received support for attending meetings and/or travel from the Obesity Medicine Association and Pfizer Inc.; served in a leadership or fiduciary role with the Obesity Medicine Association; and received stock or stock options from Eli Lilly and Company and Novo Nordisk A/S. Jamy D. Ard has received grants or contracts from Boehringer Ingelheim, Eli Lilly and Company, Epitomee, KVK Tech, Nestlé Health Science, UnitedHealth Group R&D, and WW International Inc.; received consulting fees from Brightseed, Eli Lilly and Company, Intuitive, Level2, Nestlé Health Science, Novo Nordisk A/S, OptumLabs R&D, Regeneron Pharmaceuticals, Inc., Spoke Health, and WW International Inc.; served in a leadership or fiduciary role for The Obesity Society and American Society for Nutrition Foundation; and received equipment, materials, drugs, medical writing, gifts, or other services from KVK Tech, Nestlé Health Science, and WW International Inc. Zhaoping Li has served on advisory boards for Abbott Laboratories. Jesse Richards has received grants or contracts from speakers bureaus for Eli Lilly and Company; received payment or honoraria for lectures from speakers bureaus for Novo Nordisk A/S and Rhythm Pharmaceuticals, Inc.; and served on an advisory board for Rhythm Pharmaceuticals, Inc. W. Scott Butsch has received grants from Eli Lilly and Company; consulting fees from Novo Nordisk A/S; payment from Med Learning Group and Potomac Center for Medical Education; and served on advisory boards for Abbott Laboratories, Eli Lilly and Company, Medscape, and Alfie Health. Irina Jouravskaya is an employee of Eli Lilly and Company. Kadie S. Vanderman is an employee of Syneos Health. Lisa M. Neff is an employee and stockholder of Eli Lilly and Company; has received grants or contracts from Aegerion Pharmaceuticals Inc.; and has served in a leadership or fiduciary role with Current Developments in Nutrition (journal) and the National Board of Physician Nutrition Specialists.