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Is Ozempic the Gateway Drug for CBT?

An interesting pattern is emerging from nearly two decades of prescribing GLP-1 agonists such as liraglutide or Ozempic for type 2 diabetes. A combination of studies show that GLP-1 agonists are, first, more effective when combined with cognitive behavioral therapy (CBT), and second, that CBT makes it possible to not gain all the weight back for those going off Ozempic, Wegovy, and other GLP-1 agonists.

The first study is a retrospective cohort study involving 328 individuals being treated for type 2 diabetes with GLP-1 receptor agonists. Twenty-nine of those were given an additional five group courses in elementary nutritional education (ENE).  Fifty-three were given ENE plus 12 group sessions of CBT. Therapy was completed and results were measured at six months. Follow-ups were done every six months for two years. The results:

Body weight remarkably decreased following both behavioural programmes, with significant differences compared with SC [standard care] at 2 years (CBT=8.5% weight loss; ENE=6.3% weight loss; SC=3.1% weight loss). A 10% weight loss was achieved and maintained in approximately 30% of cases during follow-up, and an additional 35% of cases lost between 5% and 10%.

The average weight loss after two years for those getting CBT was 275% of the average weight loss for those not getting therapy. Inquiring minds want to know, what’s in that CBT? The answer is complicated and intriguing.

Elementary Nutritional Education (ENE)

All of the patients receiving CBT first went through the ENE program, so it’s difficult to separate the impact of CBT alone vs. CBT + ENE. Therefore, it’s important to see what’s included in the ENE group sessions, which resulted in double the weight loss of those on GLP-1 agonists alone.

The ENE is administered in five two-hour sessions involving 20 to 25 individuals. Though the name says “nutritional education,” the focus is “lifestyle change,” and the last of the five therapy sessions is “chaired by a psychologist and deals with relapse.” The first four sessions cover the following topics:

  • energy balance, nutrients and weight monitoring
  • alimentary pyramid and size of portions
  • food shopping and food labels
  • physical activity, when and how much

Cognitive Behavioral Therapy (CBT)

Fifty-three individuals completed the five-week ENE and went on to 12 weeks of two-hour group CBT sessions with 10-15 participants. The CBT was built around The LEARN Program for Weight Management by Kelly Brownell. LEARN is an acronym for Lifestyle, Exercise, Attitudes, Relationships, and Nutrition. Subjects covered in the sessions included:

  • calorie counting
  • monitoring daily food intake
  • behavioral strategies for stimulus control
  • establishing a pattern of regular eating
  • identifying dysfunctional cognition
  • coping with dysfunctional cognition
  • identifying high-risk situations responsible for binge eating 
  • problem-solving skills
  • maintaining improvement
  • preventing relapse

The authors of this study concluded:

Initiation of GLP-1RA treatment provides an opportunity for addressing patients’ needs of weight control. By producing initial weight loss, patients’ motivation and self-efficacy are expected to increase and adherence to long-term lifestyle changes might be more easily attained.

A similar sentiment is echoed in a research article that looks at a weight loss study involving 62 women divided into a control group of 20 women receiving only medication (a GLP-1 receptor agonist) and a second group of 42 women receiving an additional eight weeks of CBT.  The CBT this time consisted of:

[A]ccepting changes in eating behavior caused by medication and adapting to new eating habits. Work[ing] with the therapist to become aware of and accept the changes in life that occur when medications suppress appetite and weight loss is observed.

Once again, we have the need to accept a certain disappointment that comes from not using eating to displace stress and anxiety. Other methods of displacing stress must be adopted in order to maintain the weight loss initiated by the GLP-1 agonists. Some of the modules in the CBT training included developing an active lifestyle, overcoming barriers to weight loss, and tapering off medication.

In this study, which has not been peer-reviewed, those with CBT lost nearly twice the weight: an average of 5.3 kg to 2.9 kg for those who had medication only. Separately, journalist Johann Hari was prescribed liraglutide (Ozempic and Wegovy) and lost 42 lbs, he told “TODAY” last week. However, his inability to binge eat comfort food as a way of coping with stress bummed him out.

I realized how much of my eating was about the need to comfort myself — stuffing myself to calm myself. And I couldn’t do that when I was on Ozempic.

It’s beginning to look like Ozempic is the gateway drug for CBT. The GLP-1 agonists take the joy out of binging, but the stress still needs to be displaced. CBT opens up users to the possibilities of making lifestyle changes they previously would not have considered possible. Those lifestyle changes can help wean people off GLP-1 drugs or cope when they stop taking them.

Written by Steve O’Keefe. First published June 25, 2024.


“Combination of GLP-1 receptor agonists and behavioural treatment in type 2 diabetes elicits synergistic effects on body weight: A retrospective cohort study,” Endocrinology, Diabetes & Metabolism, October 2019.

The Learn Program for Weight Management, by Kelly Brownell, American Health Publishing, January 1991.

“Ozempic Patient Shares ‘Psychological Effects’ That Made Him Want to Quit,” BestLife, June 21, 2024.

“Is Ozempic a ‘magic’ drug? Author who lost 42 pounds on benefits, ‘very real concerns’,” “TODAY,” June 20, 2024.

Image Copyright: chemist4u, used under Creative Commons license.


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