In 2021, the prevalence of type 2 diabetes (T2D) rose to an estimated 38.4 million adults (nearly 15% of US adults). 1.
The American Diabetes Association (ADA) standards for diabetes management have evolved significantly in recent years, with the 2025 standard recommending SGLT2 inhibitors and GLP1 RAS as a first-line, glucose-lowering agent for all patients with diabetes. It prevents progression from pre-diabetes to T2D, and total weight loss can lead to T2D remission of just 10-15%. It is not surprising that GLP1RAS usage is rising rapidly, with 12% of all US adults and 43% of T2D reporting GLP1 RA use.
Physiologically, enterocytes respond to digested nutrients by secreting GLP1 into the blood and directly triggering nerves that trigger directly into brain regions that control energy intake and reward. Tilzepatide (Dual Glucose-Dependent Insulinotropic Polypeptide (GIP)/GLP1 RA) is the most potent trophic zonal incretin hormone-based therapy on the market.
Among patients with T2D, semaglutide and tilzepatide, simaglutide and tilzepatide result in an average weight loss of 6.2% and 11.6% over the course of 1 year. 4 Placebo-adjusted weight loss in patients without 4 diabetes: 12.4% for semaglutide and 17.8% for tilzepatide. Obesity-promoting drugs, concerns about hypoglycemia, reduced diabetes, microbiome variation, genetic predisposition to weight gain, differences in endogenous GLP-1 pathways in the brain and other tissues7,9
GLP1 RA-based treatments can play an important role in T2D and weight management, but should not be prescribed without comprehensive lifestyle interventions. Such interventions are key to supporting overall health, and without the use of GLP1 RA, they would have lost more than 10% weight in almost 30% of T2D patients in 8 years.
Furthermore, there are significant challenges in the use of GLP1 RA. Frequent gastrointestinal side effects, risk of nutritional deficiency, muscle and bone loss, high costs, and limited accessibility. These factors contribute more than 35% of T2D patients who discontinue GLP1 RA use in one year.
Therefore, comprehensive lifestyle interventions focus on nutrition for weight and side effects management, resistance exercise to maintain bone health, and sleep/stress management, and may address some of the challenges associated with the use of GLP1 RA. The Lifestyle intervention may maintain weight maintenance and metabolic health after discontinuation of GLP1 RA. 11,12. Importantly, these structured lifestyle interventions may support the more effective use of these drugs, as they are contributors of a significant, $400 billion annually to US healthcare costs for patients with T2D.4,133.
It is important to take a patient-centered approach when discussing changes in weight and lifestyle. This includes taking care to minimize weight stigma. This can damage the relationship between patients' clinicians, delayed care or cancelled, and reduced treatment effectiveness. Screening for eating disorders should be completed as necessary with patient specialist referral before prescribing GLP1 RA. 16,17
A healthy dietary pattern spectrum is recommended for diabetic patients with GLP1S. These include low-fat vegan/vegetarian, low-carb and Mediterranean dietary patterns, while 4,8 share a common foundation of minimally processed, fiber and nutrient-rich foods, including fruits, vegetables, legumes, nuts, seeds, vegetable oils, dairy products, sea and seafood. Avoid ultra-high processing and restaurant foods, containing refined starch, sugar, salt and additives.
Although additional research is needed to identify specific dietary patterns that maximize treatment effectiveness, patient-centered approaches should take into account socioeconomic barriers to individual food and cultural preferences, healthy food access, and dietary quality. Access to health-promoting dietary patterns for managing diseases in conjunction with GLP1 RAS and related treatments17,19,20
This article was written by Ryan M. Kane, MD, MPH of the Duke University School of Medicine and Dariush Mozaffarian, DRPH, FACC, Tufts University and Tufts Medical Center.
reference
Centers for Disease Control and Prevention. National Diabetes Statistics Report. May 15, 2024. Please visit here. https://www.cdc.gov/diabetes/php/data-research/index.html Committee Adapp. 9. Pharmacological approach to glucose treatment: Criteria for care in diabetes—2025. Diabetes Care 2024; 48 (Supplementary_1): S181-S206. Montero A, Sparks G, Presiado M, Hamel L. KFF Health Tracking Poll May 2024: Public Use and Views of GLP-1 Drugs. KFF. Updated May 10, 2024. Accessed on April 14th, 2025. Access from here. https://www.kff.org/health-costs/poll-finding/kff-health-tracking-poll-may-2024-the-publics-use-and-views-of-glp-1-drugs/Committee Adapp. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: Criteria for diabetes care – 2025. Diabetes Care 2024; 48 (Supplementary_1): S167-S180. Morton GJ, Meek TH, Schwartz MW. Neurobiology of food intake in health and illness. Nat Rev Neurosci June 2014; 15(6): 367-78. Bodnaruc AM, Prud'homme D, Blanchet R, Giroux I. Nutrient regulation of endogenous glucagon-like peptide-1 secretion: a review. Nutrition and metabolism 2016; 13:92. Huber H, Schieren A, Holst JJ, Simon MC. The effects of diet on GLP-1 secretion of fasting and stimulation under various metabolic conditions – a review of the story. Am J Clin Nutr 2024; 119:599-627. doi: https://doi.org/10.1016/j.ajcnut.2024.01.007. Obesity management in Elmaleh-Sachs A, Schwartz JL, Bramante CT, and others adults: a review. JAMA 2023; 330: 2000-15. Jensterle M, Rizzo M, Haluzík M, JanežA. Efficacy of GLP-1 RA approved for patient weight management with or without diabetes: a narrative review. Adv Ther 2022; 39:2452-67. Please look at the research group first. 8 Years of Weight Loss with Intensive Lifestyle Intervention: The Look The Afver Study. Obesity (Silver Spring) 2014; 22:5-13. Maintaining healthy weight loss with exercise, GLP-1 receptor agonists, or combinations of Jensen SBK, Blond MB, Sandsdal RM, or a combination of both, followed by 1 year without treatment: post-treatment analysis of a randomized, placebo-controlled trial. EclinicalMedicine 2024; 69: doi: 10.1016/j.eclinm.2024.102475. Bone health after Jensen SBK, SørensenV, Sandsdal RM, other exercise alone, GLP-1 receptor agonist treatment, or combination treatment: a secondary analysis of randomized clinical trials. JAMA Network Open 2024; 7: E2416775-E2416775. Parker Ed, Lynn J, Mahony T, and others 2022 economic costs of diabetes in the US. Diabetes Care 2024; 47:26-43. Perceived weight stigma and patient-centered language use preferences in Kane RM, Williams SB, Reynolds K, and others: A cross-sectional mixing method analysis conducted at large academic medical centers. PLOS ONE 2025; 20: E0314269. The importance of language in engagement between Albury C, strain WD, Brocq SL, and other health professionals and people with obesity: a joint consensus statement. Lancet Diabetic Endocrinol 2020; 8:447-55. GLP-1 receptor agonists such as Aoun L, Almardini S, Saliba F: New drug therapy for bulimia (bulimia and bulimia nervosa)? Systematic review. J Clin Transl Endocrinol 2024; 35:100333. Nutritional considerations with Almandoz JP, Wadden TA, Tewksbury C, and other antibesity drugs. Obesity 2024; 32:1613-31. Berkowitz SA, Seligman HK, Mozaffarian D. New approaches to steer research and policy at the intersection of income, food, nutrition and health. Health Affairs 2025; 44:384-390. Mozaffarian D, Aspry KE, Garfield K, et al. “Foods are Medicines” Strategies for Nutritional Security and Cardio-Metabolic Health Equity: JACC's cutting-edge review. J Am Coll Cardiol 2024; 83:843-64. Garfield K, Hanson E, Shachar C, Stain P, and Mozaffarian D. stated “using Medicaid managed care” in place of services to address malnutrition. Health Affairs 2025; 44:422-28.
Clinical Topics: Prevention, Diet
Keywords: Heart Disease Journal, ACC Publications, Semaglutide, Sodium-Glucose Transporter 2 Inhibitor, Glucagon-Like Peptide 1, Diabetes, Type 2, Diet
