Riccardo Dalle Grave, MD
Kushner, Chao, and Wadden, in an article published in JAMA in May 2026, analyze the role of lifestyle modification in the era of new incretin-based therapies for obesity, particularly semaglutide and tirzepatide. The authors emphasize how these medications have profoundly changed obesity treatment through their ability to reduce appetite, cravings, and energy intake, enabling significantly greater weight loss than that achieved with traditional intensive lifestyle intervention programs.
One of the most interesting aspects of the article concerns the redefinition of behavioral therapy’s role. The authors note that traditional intensive lifestyle modification programs involved numerous meetings with healthcare professionals—up to 28 sessions over 56 weeks—yet achieved relatively modest body weight results (average weight loss of 5% to 8%). In contrast, studies with semaglutide and tirzepatide have demonstrated much greater weight loss with a substantially lower number of lifestyle counseling visits. In the STEP 1 trial, for example, semaglutide, with only 18 visits over 68 weeks, produced a 14.9% reduction in body weight, whereas in STEP 3, with 30 visits, weight loss reached 16%, only slightly higher. Furthermore, in the SURMOUNT-5 trial, semaglutide and tirzepatide were combined with only 9 lifestyle counseling visits over 72 weeks, yet still achieved highly significant body weight reduction.
The authors therefore propose a revision of the therapeutic paradigm: no longer pharmacotherapy as a support to lifestyle intervention, but rather lifestyle modification as a complement to pharmacological therapy. Nevertheless, the article continues to stress the importance of nutritional counseling and physical activity in preserving muscle mass and cardiometabolic health, managing gastrointestinal side effects, and supporting long-term weight maintenance.
Commentary
The article represents an important contribution because it documents how new incretin-based therapies are profoundly changing the treatment of obesity. However, in the proposed model, the psychological dimension of treatment remains underdeveloped.
The management of obesity cannot, in fact, be limited to medical, nutritional, and physical activity aspects alone. Many patients live with years of weight-related stigma and internalized stigma that affect their self-esteem, quality of life, body image, and motivation for treatment. Psychological support can help patients recognize and address these experiences, reducing the risk that the treatment of obesity is experienced exclusively as a search for the “ideal weight” and the reduction of the medical burden associated with obesity.
It would also be important to explore the goals patients set for themselves in relation to weight loss. These goals are not always realistic or directly connected to health; sometimes patients seek weight loss as a solution to relational, social, or identity-related difficulties. In the absence of adequate psychological support, this may lead to excessive expectations, followed by frustration.
Another insufficiently considered aspect is body image. Even after significant weight loss, many individuals continue to experience dissatisfaction with their bodies or difficulty accepting them. This factor may affect both treatment adherence and the long-term maintenance of results.
Finally, greater attention should be devoted to the prevention and management of eating disorders that may coexist with obesity, such as binge-eating disorder or other dysfunctional eating behaviors. The strong focus on weight and dietary control, even in the presence of highly effective medications, requires careful clinical monitoring of the patient’s psychological health.
New incretin-based therapies undoubtedly represent a major advance, but precisely because of their effectiveness, they make a multidisciplinary approach even more necessary—one that integrates medical, nutritional, and psychological expertise while keeping the overall well-being of the person with obesity at the center of care.
Reference
Kushner, R. F., Chao, A. M., & Wadden, T. A. (2026). Lifestyle Modification and Incretin-Based Therapy for Obesity. JAMA. https://doi.org/10.1001/jama.2026.4106