When "Eat Less & Move More" Meets GLP‑1s: Why Blaming Patients Misses the Point
Last week, I gave a presentation on GLP‑1 medications to a room of engaged, thoughtful registered dietitians. During the Q&A, someone asked:
“What do you do when a patient doesn’t lose enough weight on a GLP‑1?”
Before I could answer, another audience member chimed in:
“They’ll lose weight if they finally eat like we tell them to. They just refuse to do that.”
There were nods of agreement around the room.
My response could have been more elegant, but it something along the lines of: “We shouldn’t blame the patients.” I could tell immediately it created an awkward moment and left some audience members somewhat uncomfortable.
It was a moment that stuck with me, and one worth unpacking.
The Hidden Assumption: Good Health Must Be Earned
Beneath that comment lies a deeply ingrained belief:
If someone isn’t losing weight, it’s because they didn’t try hard enough.
This thinking positions good health as a moral reward — something granted only to people who follow instructions perfectly.
But obesity is not a character flaw. It’s a chronic, relapsing, biologically driven disease. And I want good health for every patient — whether or not they:
Count calories
Drink sugar sweetened beverages
Shop at the farmers' market
Lift Weights
have the time, resources, or support to “do everything right”
Health should not be a prize for compliance.
Diet‑Culture Thinking Is Alive and Well — Even in Healthcare
Many clinicians don’t realize how often we slip into subtle shame‑based narratives:
“They just need more discipline.”
“They don’t want it badly enough.”
“If they’d only follow the plan…”
These statements imply that lack of weight loss = lack of effort.
But for many patients, effort is not the issue — access, biology, stress, trauma, and socioeconomic barriers are.
And yes — this was an audience of RDs. Professionally, culturally, and academically, there may be bias toward the belief that nutritional behavior change is always the determining factor.
It isn’t.
Patients Are Usually Doing the Best They Can
Some patients truly do have the privilege of structure — they know nutrition well, have time to cook, can afford fresh ingredients, and live in supportive environments. Others are juggling realities that make sustained behavior change extraordinarily difficult: multiple jobs, caregiving demands, unpredictable schedules, financial strain, limited access to safe or affordable food, inadequate kitchen space, chronic stress, poor sleep, or low health literacy.
Most aren’t “refusing” lifestyle change — they’re doing the best they can with the bandwidth, resources, and energy available to them. They are not being difficult. They are being human.
The Evidence: Lifestyle Alone Isn’t What’s Driving GLP‑1 Outcomes
A commonly repeated refrain:
“You can’t just rely on the medication — you still have to eat right and exercise.”
This dogmatic argument is repeated with almost religious zeal. While not un-true, it's certainly not helpful.
In every major GLP‑1 clinical trial, both the placebo and medication groups received intensive lifestyle intervention — structured nutrition counseling, exercise guidance, behavioral support.
Nobody got the medication without lifestyle support.
Still, the people on medication lost dramatically more weight, despite similar lifestyle programming. That tells us something important:
Biology matters.
And endlessly tightening calories or “dieting harder” doesn’t guarantee additional weight loss on GLP‑1s — especially when appetite is already suppressed.
Put another way: we cannot willpower or shame patients into a different metabolic response.
What “Lifestyle Change” Should Mean in the GLP‑1 Era
We need a reframing. Lifestyle support is still essential — but not in the traditional “eat less, exercise more” way.
On GLP‑1 medications, lifestyle care should prioritize:
✅ Preserving muscle mass through resistance training
✅ Adequate protein intake to support lean tissue
✅ Managing side effects — structured meals, hydration, gentle fiber intake
✅ Building sustainable habits, not temporary restriction
✅ Respecting individual capacity and barriers
It should not mean:
🚫 insisting on perfection
🚫 blaming the patient for physiologic variability in response
🚫 pushing starvation‑level calorie deficits
🚫 assuming lack of weight loss = lack of effort
If a patient on a GLP‑1 doesn’t lose “enough” weight, the first step should be medical inquiry — not judgment.
Why Patient‑Blame Is Clinically Harmful
When clinicians suggest — directly or indirectly — that insufficient weight loss reflects insufficient effort, patients often withdraw emotionally or physically from care. They may stop sharing honest challenges, skip appointments, or internalize a sense of failure. Shame erodes trust, and trust is essential for long‑term treatment of any chronic disease.
Blame doesn’t motivate change — it fractures the therapeutic relationship. Patients deserve collaborative problem‑solving, not moral evaluation.
A Better Question for Clinicians to Ask
Instead of defaulting to “Why didn’t you follow the plan?” we can approach with curiosity: What got in the way this week? How can the strategy better fit the patient’s real life? What support, structure, or resources would make change more realistic? And importantly — what does success mean to them, not to us?
We don’t need stricter rules — we need better listening. Empowerment grows not from telling patients what they should do, but from helping them explore what is possible, sustainable, and compassionate within their circumstances.
Final Thought: Health Is Not a Test People Pass or Fail
GLP‑1 medications didn’t create entitlement, laziness, shortcuts, or moral decay
They created an opportunity.
For many people, for the first time, biology isn’t fighting back at every turn.
Our job is not to decide who deserves that opportunity.
Our job is to help people use it safely, compassionately, and sustainably.
Good health shouldn’t be earned — it should be supported.
