Weight Loss Treatments

Overview

Obesity vs. overweight

Being overweight or obese are both terms for having more body fat than what is considered healthy.

Body mass index (BMI) is a simple index of weight-for-height that is commonly used to classify overweight and obesity in adults. It is defined as a person’s weight in kilograms divided by the square of his height in meters (kg/m²). For adults, overweight and obesity are typically defined as follows:

• Overweight is a BMI greater than or equal to 25
• Obesity is a BMI greater than or equal to 30

BMI provides the most useful measure of overweight and obesity as it is the same for both sexes and for all ages of adults. However, it should be considered a rough guide because it may not correspond to the same degree of fatness in different individuals.

Fortunately, there are a variety of weight loss treatments that can help both obese and overweight patients lose weight and improve their quality of life.

Health risks

Individuals who are overweight or obese are at an elevated risk for a number of health conditions, including:

• All causes of death (i.e. early mortality)
• Coronary heart disease (the cause of heart attacks)
• High blood pressure (hypertension)
• Unhealthy cholesterol profile (high LDL and triglycerides, low HDL)
• Type 2 diabetes
• Sleep apnea and other breathing problems
• Osteoarthritis (painful degeneration of the joints)
• Some types of cancer
• Mental illness (such as depression and/or anxiety)
• Generalized body pain and difficulty with physical functions
• Elevated risk for severe illness in COVID-19
• Overall reduced quality of life.

Pregnancy and obesity

Being overweight or obese during pregnancy is associated with elevated risk for both mother and the baby. These risks increase as the BMI increases, and include:

• Difficulty conceiving
• Gestational diabetes
• Gestational hypertension
• Intra-uterine death of the fetus
• Preeclampsia (a life-threatening pregnancy condition).

Lifestyle modifications

Diet

Although the statistics show that the norm is moderate weight loss followed by weight regain, many people are able to achieve impressive weight loss results and keep it off through dedicated lifestyle modifications.

Regardless of expectations, prior to resorting to second-line weight loss treatments – as we will discuss in this article – it behooves individuals to at least lose some weight through lifestyle modifications. This is for two reasons. First, it is often required that people lose some weight through conventional means before they are eligible for other treatments, and second, because it is important for people to have a good routine to eat properly and stay active afterward, so that they can optimize and maintain their weight loss.

There is no magic diet that works for everyone, but there are some important principles that should be observed:

• Weight loss can only be achieved through a daily calorie deficit (using more Calories than you take in)
• Fiber is filling, reduces fat absorption, and its calories are largely unabsorbed
• Protein is filling, and is inefficiently metabolized, meaning that fewer calories are absorbed
• Carbohydrates (“carbs”) can be simple (refined sugars) or complex (starches and fiber). Avoiding simple carbs in favor of complex carbs is helpful for losing weight
• Low-fat diets do not work, and high-fat diets are associated with adverse outcomes
• Healthy fats (omega fatty acids) are necessary and should be included in the daily diet
• Dietary changes are useless unless they are sustainable. That means finding foods that you like and that fit in with your family’s meal plans.

Physical activity and exercise

The guidelines for physical activity published by the American College of Sports Medicine (ACSM) are endorsed by the CDC, are specific to achieving and maintaining a healthy weight, and are based on research evidence.

The ACSM guidelines suggest that adults aged 18-65 should engage in 30 minutes or more of moderate aerobic physical activity on five days per week, or vigorous aerobic activity for at least 20 minutes on three days per week. They also recommend activities directed at muscular strength and endurance on at least two days per week. The ACSM website has excellent blogs and videos with specifics and suggestions on how to meet these goals in your everyday activities.

Research has shown that additional benefit derived by training beyond six days per week is minimal and is complicated by higher injury rates. Components of a particular training session include the warm-up, conditioning phase, and cool-down. The 5 -20 minute warm-up prepares muscles for more vigorous exercise and may reduce injuries. Stretching is recommended following the warm-up and is thought to reduce muscular injury. The conditioning phase involves a cardio-respiratory or resistance training session lasting 20 to 60 minutes. This is followed by a cool-down, which helps reduce soreness and injury.

Weight loss medications

In addition to diet and exercise, some people may benefit from other weight loss options, such as medications for weight loss. It is important to view medications as a second-line weight loss modality, to be used as an adjunct to diet and physical activity.

Weight loss medications are not a magic solutions to obesity. Rather, they can assist people with their weight loss efforts, and should be used with a healthy diet and exercise plan, not in place of them.

The available medications work in different ways, but generally they either help curb appetite or interfere with the body’s absorption of dietary fat. In general, weight loss medications are meant for people with a BMI of 30 or higher, or a BMI of 27 or higher and have weight-related health problems, such as type 2 diabetes or high blood pressure.

Some FDA-approved weight loss medications currently available are:

• Orlistat (Xenical): reduces absorption of dietary fat
• Lorcaserin (Belviq): this was withdrawn from the U.S. market in February 2020 due to concerns with increased rates of cancer
• Phentermine-topiramate (Qsymia): this is a combination of phentermine, which reduces appetite, and topiramate, which makes you feel full sooner
• Naltrexone-bupropion (Contrave): this two-drug combination is believed to make you feel full sooner and less hungry between meals
• Liraglutide (Saxenda): this drug is available by injection only, and is believed to make you feel full sooner and less hungry

Other appetite suppressants available for short-term use (up to 12 weeks) only:

• phentermine
• benzphetamine
• diethylpropion
• phendimetrazine

These drugs are available by prescription only, except Orlistat, which is available in a lower dose form over-the-counter, under the brand name Alli.

Surgical procedures

If you are significantly overweight, or your excess weight is causing health issues, weight loss surgery – known as “bariatric” surgery – may an option for you. Surgery is generally for people who have already put significant efforts into lowering their weight through lifestyle medications.

Bariatric surgery has proven to be the most efficacious way to lose weight and improve weight-related disease. Most surgeons require their patients to lose weight prior to surgery, in order to lessen the risk of complications, and to prove that they are capable of eating right and engaging in physical activity after having surgery.

Before considering surgery, you will be asked to commit to living a healthy life, including a healthy diet and exercise to optimize weight loss, prevent complications, and prevent weight re-gain.

Bariatric surgical procedures are either restrictive (reduce the amount of food the stomach can hold), malabsorptive (reduce the amount of food that the body absorbs from the diet), or a mixture of both. There are a number of types of bariatric surgery available:

• Gastric Bypass (“Roux-en-Y”): gastric bypass is a mixed procedure, the surgeon creates a small pouch from the upper part of the stomach, restricting the amount of food it will hold. The pouch is then attached to the intestine further on than normal, so as to reduce absorption of Calories.
• Gastric Banding: often done laparascopically (therefore is called “lap banding”), this procedure places an adjustable band around the stomach, creating a small pouch and outlet. Some are adjustable (such as the Lap Band System)
• Gastric Sleeve: with gastric sleeve surgery, the doctor makes a narrow tube out of the stomach so that it holds less food and makes less ghrelin, the hormone that makes you feel hungry
• Endoscopically placed devices: these incision-free weight loss procedures, minimally-invasive procedures involve placing devices using an endoscope (a tube with a camera) inserted in the stomach and intestines through the mouth. The devices implanted include gastric balloons and intestinal endoluminal sleeves
• Intermittent vagal blockade: a novel procedure, involving placing electrodes on the nerve that innervates the stomach to reduce appetite.

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