Nutritional Rehabilitation in a Client with Brain Injury and Pharmacologically-Induced Weight Loss

Background

support from his support worker and his partner. He receives multidisciplinary neurorehabilitation input, including physiotherapy and specialist dietetics. Client C self-reported that his highest recorded weight was 144 kg, reached approximately three to four years before dietetic involvement, following a prolonged period of immobility, emotional eating, and disrupted routines.

By the time of his referral to community dietetics in March 2023, Client C’s weight had decreased to 106.6 kg (BMI 39.0). This reduction was primarily attributed to the use of Ozempic (Semaglutide), which Client C had been accessing online without clinical oversight. The medication was not prescribed or monitored through NHS or private medical channels, and his only required action was to update his weight on the online platform. He did not undergo blood monitoring or formal clinical review during this time.

Nutritional advice during this period had been provided informally through a personal trainer who had completed a nutrition course, but who was not an HCPC-registered healthcare professional. This led to a period of weight loss without safe oversight or individualised assessment of nutritional adequacy, increasing the risk of malnutrition and muscle loss.

Assessment

When first assessed in March 2023, Client C described significant appetite suppression and minimal dietary intake. He was typically consuming only one meal per day—often a takeaway or processed meal in the evening—and reported skipping breakfast entirely. Snacking patterns included sweets and low-calorie desserts, with a reliance on sugary fluids for bowel regulation. Fruit, vegetables, whole grains, and high-quality protein were notably lacking from his diet.

At this point, he had already lost over a stone and a half in under three months since starting Ozempic. However, there had been no structured monitoring by a healthcare professional, and Client C had not undergone blood work or body composition assessment during this time. His only source of dietary input had been a personal trainer offering generalised nutrition advice, which, while well-meaning, did not meet the standards of clinical dietetic care or account for his neurological and gastrointestinal complexities.

This unmonitored approach, combined with the pharmacological appetite suppression, left Client C at significant risk of sarcopenia, micronutrient deficiency, and functional fatigue. His engagement with physiotherapy and gym-based activity was commendable, but his limited stamina and increased fatigue after low intake days indicated emerging undernutrition.

Care Plan

The care plan aimed to preserve lean mass, support functional recovery, and address the nutritional risks associated with rapid pharmacologically induced weight loss. Given Client C’s aversion to large meals and reduced appetite, the plan emphasised regular, small, protein-rich snacks and meals, while gradually reducing reliance on takeaways and ultra-processed foods.

Client C was provided with nutrition education covering:

• The impact of GLP-1 medication on appetite and muscle preservation
• The role of protein in post-exercise recovery and energy
• Risks of sarcopenia and malnutrition in the context of neurodisability
• Long-term dietary patterns for maintaining weight post-pharmacotherapy

In addition, efforts were made to introduce practical meal plans and healthy recipes that could replace takeaway habits. However, Client C found structured meal plans difficult to follow. He preferred repetition—eating the same food for a period of time—before suddenly losing interest in it, often reverting back to takeaways when preferences changed. This cyclical pattern required a flexible, person-centred approach that responded to sensory fatigue, emotional overwhelm, and executive functioning difficulties.

To support bone and micronutrient health, Client C was started on a multivitamin and Vitamin D supplement, alongside guidance on calcium-rich foods and hydration strategies. Fibre supplementation (Fybogel) was added to his existing laxatives to improve bowel regularity.

Intervention

As Client C transitioned from Ozempic to Mounjaro (Tirzepatide) in late 2023, the risk of sarcopenic weight loss became more pronounced. Despite improved metabolic outcomes, his intake remained insufficient to meet energy and protein needs. Energy requirements were estimated at 1,936 kcal/day using adjusted body weight (74.5 kg), with a protein goal of 130–140 g/day.

Client C was supported to integrate:

• High-protein smoothies post-gym sessions
• Ready-to-eat snacks such as yoghurts, protein puddings, and bars
• Easy meal ideas developed in collaboration with his brother
• Portion-controlled, lower-effort alternatives to takeaways (e.g. grilled chicken wraps, air-fried lean meats)

Attempts to implement detailed weekly meal plans were abandoned in favour of a rotating list of tolerated meals and snacks. Education was repeated across sessions, respecting Client C’s need for pacing and reinforcement. Fatigue, low mood, and grief

frequently disrupted adherence, but the supportive role of his brother proved key in reintroducing food when Client C disengaged.

Outcomes

Between March 2023 and January 2025, Client C’s weight decreased from 106.6 kg to 87.2 kg, with an estimated loss of over 6.8–7 kg in fat-free mass. His nutritional intake improved modestly, particularly around exercise sessions, with Client C reporting reduced fatigue when consuming smoothies post-gym. Although he continued to cycle in and out of takeaway use, his understanding of nutrition, energy, and appetite management improved.

In March 2025, a private DEXA scan showed excellent bone density, with T-scores of +2.6 to +2.8 across lumbar spine and hip, ruling out osteopaenia or osteoporosis. This reassured Client C and the MDT that bone mass was being preserved, even as muscle mass declined.

Positive changes included:

• A more consistent breakfast and snack routine
• Improved awareness of the link between food, energy, and exercise
• Reduced reliance on high-sugar, nutrient-poor foods
• Ongoing family involvement in food planning and preparation

Challenges remain around appetite suppression, low motivation, and Client C’s tendency to disengage from food when emotionally overwhelmed. Structured meal plans have not been sustainable; a flexible, supportive approach remains essential.

Reflection

Client C’s case offers a powerful example of how thoughtful, sustained nutritional care can support meaningful transformation—not just in body composition, but in function, independence, and quality of life. Since engaging with the service, Client C has lost over 50 kg from his highest recorded weight of 144 kg. This weight loss—though clinically significant—has meant far more than numbers on a scale. It has translated into tangible improvements in his daily life: he is now more mobile, no longer reliant on a wheelchair (having avoided its use for over 18 months), and has returned to previously unimaginable activities such as skiing and holidaying regularly.

While his journey has not been without complexity, it is a testament to what becomes possible when care is consistent, adaptive, and relational. Early concerns around sarcopenic weight loss and appetite suppression led us to reframe our focus—from weight loss to weight stability, and from dietary compliance to nutritional resilience. Client C responded positively to this shift. His protein intake improved, his post-exercise recovery stabilised, and his understanding of food as a tool for energy and function—not just weight management—deepened over time.

That said, Client C is now navigating a new phase of uncertainty. As his bodyweight has decreased and the side effects of Mounjaro at full dose (15 mg) have intensified, we have begun titrating him off the medication. Client C has voiced understandable concerns about this transition: fears of weight regain, fluctuating appetite, and whether he will be able to maintain the progress he’s worked so hard for. These are valid worries. We are supporting him closely through this tapering process—helping him re-establish food rhythms, honour hunger signals, and build a diet that is nourishing, sustainable, and emotionally grounded.

What this case has reaffirmed is that weight loss—particularly in the context of neurological disability—must be supported by wraparound care that safeguards muscle, mood, meaning, and movement. Client C has demonstrated not only clinical progress but personal growth, rebuilding a relationship with food that is flexible, functional, and more forgiving.

His case calls us to remember that nutritional care doesn’t end when the weight target is reached. It continues as the body changes, the medication shifts, and new possibilities open up. With continued support, Client C is not just maintaining progress—he is reclaiming mobility, joy, and autonomy.