The Hidden Gaps in GLP-1RA Care
11th Aug, 2026
David is a 69-year-old retired farmer whom I have had the privilege of caring for over many years. He had always lived with obesity. Four years ago, he lost his wife. Grief and loneliness consumed him, and food became a crutch; it numbed the loss, if only briefly. Over the following years, I watched his weight slowly increase.
Then, one morning, he walked into my consulting room looking like a different man. He had found himself a new girlfriend. For the first time in years, he wasn’t talking about loss. He was talking about going for walks, booking holidays and looking forward to the future. He wanted to improve his health not because someone had told him he should, but because he had found joy again.
We commenced Ozempic treatment for his diabetes and weight management. He had previously declined GLP-1RA treatment.
We discussed the contraindications, common side effects and the importance of a healthy lifestyle: a nutrient-dense diet, good hydration, portion control, resistance exercise and a daily multivitamin. Four weeks later, David returned for his GLP-1RA treatment review. He was beaming. He had lost weight. “The food noise has gone,” he said. I was pleased for him.
Then I asked him a question I ask every patient taking a GLP-1RA therapy.
“What did you eat yesterday?”
“Breakfast.”
“And after that?”
“Tomatoes.”
“Anything else?”
“No… just tomatoes.”
Not because he was trying to starve himself. Simply because he wasn’t hungry, and losing weight felt great. At that moment, something changed in my own thinking.
We prescribe a medication that suppresses appetite, yet many of our patients have never had to think about how to nourish themselves in the absence of hunger. Appetite suppression is not the same as nutritional adequacy.
We spent the rest of the consultation talking, not about dose escalation but about his daily protein intake target, preserving muscle mass, choosing nutrient-dense foods, shopping habits and why improving health should never come at the expense of nutrition.
Looking back, that conversation was probably more important than writing the prescription itself.
Four weeks ago, our Integrated Care Board gave primary care the green light to prescribe GLP-1RA therapies for obesity without first referring eligible patients to specialist Tier 3 weight management services or a federation-led prescribing service. This should have been a moment of celebration. For years, I had watched patients wait months for treatment while living with a chronic disease that affected every aspect of their health. Finally, we could offer effective treatment without unnecessary delays.
Instead of excitement, I felt apprehensive. Not because I doubt the medication. I doubt the system surrounding it.
Can we deliver this service safely? Obesity is often associated with poor diet quality and can represent a paradoxical form of malnutrition: excess energy intake alongside deficiencies in essential micronutrients. These deficiencies can affect physical health, cognitive function, emotional wellbeing and daily performance (Kobylińska et al.). Older adults with obesity, people from more deprived backgrounds and those with long-term conditions have higher rates of muscle loss and micronutrient deficiency, with prevalence reported at up to 50% (Fallows, 2025). People living with obesity are among the most vulnerable patients we care for. Unlike conditions such as rheumatoid arthritis or diabetes, obesity is often visible before a patient has spoken. Many have experienced years of stigma, repeated cycles of dieting, and feelings of shame and self-blame.
Who will support people whose relationship with food is shaped not only by appetite, but also by genetics, culture, socioeconomic status, environment and adverse childhood experiences?
I had recently cared for another patient whose illness would later become the subject of my published case report (Zaidy, 2026).
She developed Wernicke’s encephalopathy following profound nutritional deficiency. Her presentation was undoubtedly multifactorial, and it would be wrong to attribute it solely to GLP-1RA therapy. However, one fact remains difficult to ignore: severe nutritional deficiency played a significant role, and much of it may have been preventable through earlier recognition and intervention (Zaidy, 2026).
We should ask ourselves: what does success actually look like? Imagine a patient who loses 20% of their body weight. Their HbA1c normalises, their blood pressure improves and their MASLD improves. We congratulate them on their metabolic success, and yet another story may be unfolding.
Vitamin D deficiency has been reported as the most common nutritional abnormality in GLP-1RA users, occurring in 7.5% at 6 months and 13.6% at 12 months (Urbina et al., 2026). Overall, nutritional deficiencies were diagnosed in 12.7% of patients within 6 months after GLP-1 initiation and in 22.4% within 12 months (Butsch et al., 2025).
Protein and calcium insufficiency may contribute to lean mass loss, while thiamine and cobalamin deficits can increase over time. GLP-1RA therapy is associated with meaningful nutritional deficiencies (Urbina et al., 2026). Dehydration was the most frequent adverse event contributing to serious outcomes for several GLP-1 RAs, particularly noted in semaglutide, dulaglutide, liraglutide and tirzepatide (He et al., 2024). This is the hidden gap in GLP-1RA therapy.
Clinical trials have rightly demonstrated extraordinary efficacy, but they are conducted within highly structured environments with multidisciplinary support and regular follow-up. Life gets busy and messy. Patients miss appointments. Food shopping habits do not change overnight. Hospital admissions interrupt treatment. People may stop eating long before they learn how to eat differently.
As GLP-1RA therapies become embedded within primary care, we are moving beyond a prescribing challenge and into a lifestyle medicine challenge.
GLP-1RA therapies do not replace the wraparound support that is needed.
Lifestyle medicine is no longer an optional extra that sits alongside pharmacotherapy. It is the foundation that allows GLP-1RA pharmacotherapy to succeed.
Currently available GLP-1RA prescribing templates, do not adequately prompt nutritional assessment, and this gap needs to be addressed. A robust GLP-1RA prescribing framework should include nutritional assessment, protein intake optimisation, resistance exercise advice, psychological support, women’s health considerations, continuity of care across healthcare settings, and early recognition of complications such as sarcopenia and micronutrient deficiency. Patients’ experience of care can vary significantly depending on where they live, so clinicians should confirm how their Integrated Care Board is delivering the service. Delivery models may differ, with some areas commissioning general practice to provide the full pathway and others assigning elements such as prescribing or wraparound support to external providers.
As clinicians, we can prescribe GLP-1RA therapies, but we cannot prescribe a healthier food environment. If we are serious about tackling obesity, public health and policy must move higher up the political agenda. Patients deserve access to prevention, healthier choices and multidisciplinary support, not just a prescription.
References
• Fallows, Ellen. “Malnutrition with Use of GLP-1 Agonists Is an Underestimated Real-World Harm.” PubMed, vol. 390, 21 July 2025, pp. r1512-r1512, 10.1136/bmj.r1512.
• He, Long, et al. “Pharmacovigilance Study of GLP-1 Receptor Agonists for Metabolic and Nutritional Adverse Events.” Frontiers in Pharmacology, vol. 15, 8 July 2024, pmc.ncbi.nlm.nih.gov/articles/PMC11260617/, https://doi.org/10.3389/fphar.2024.1416985.
• Kobylińska, Milena, et al. “Malnutrition in Obesity: Is It Possible?” Obesity Facts, vol. 15, no. 1, 8 Nov. 2021, pp. 19–25, https://www.karger.com/Article/FullText/519503, 10.1159/000519503.
• Scott Butsch, W., et al. “Nutritional Deficiencies and Muscle Loss in Adults with Type 2 Diabetes Using GLP-1 Receptor Agonists: A Retrospective Observational Study.” Obesity Pillars, vol. 15, Sept. 2025, p. 100186, https://doi.org/10.1016/j.obpill.2025.100186.
• Urbina, Jorge, et al. “Micronutrient and Nutritional Deficiencies Associated with GLP-1 Receptor Agonist Therapy: A Narrative Review.” Clinical Obesity, vol. 16, no. 1, Feb. 2026, p. e70070, pubmed.ncbi.nlm.nih.gov/41549912/, https://doi.org/10.1111/cob.70070.
• Zaidy, Yasmin. “Wernicke’s Encephalopathy Following Tirzepatide Therapy in a Non-Alcoholic Patient with Autoimmune Hepatitis/Primary Biliary Cholangitis and Diabetes: A Case Report.” British Journal of Diabetes, 18 May 2026, https://doi.org/10.15277/bjd.2026.502. Accessed 28 June 2026.
Patient note
David is a composite of several patients I have had the privilege of treating with GLP-1RA therapies. Details have been changed to protect anonymity and confidentiality.
Author bio
Dr Yasmin Zaidy is a GP partner based in East Yorkshire, with specialist interests in diabetes, lifestyle medicine and obesity.
Disclosure
The author has no conflicts of interest to declare.