Obesity: What really works when it comes to losing weight
June 09, 2017
In my 16 years of family medicine, I think the most frustrating disease I’ve treated is obesity. As a doctor I feel great compassion for patients who try so hard to lose weight. Yet I haven’t been able to offer much in terms of medicine to help. Now that I'm back in the U.S. after 10 years in China, I can see how the nation’s struggle with obesity has worsened. Today, more than two-thirds of Americans are overweight or obese. So now, driven to seriously tackle this epidemic, I've scoured the literature for the most up-to-date, evidence-based advice on losing weight. Please share this with friends and family who are considering weight-loss options.
Let me jump right into perhaps my most controversial position: I think that many, many more people should consider weight-loss surgery. It’s the most effective way to permanently lose weight, and it can put diabetes in remission, improve your life expectancy and lower your risk of heart disease. It’s so effective that a huge percentage of people who have weight-loss surgery can stop taking diabetes medicine.
Don't believe me? Take a look at a 2015 meta-analysis from JAMA and a 2014 Cochrane Library review.
There are three major surgical options.
Sleeve gastrectomy: This procedure, now the most popular, involves stapling off around 75 percent of the stomach. Average weight loss is 56 percent.
Roux-en-Y gastric bypass: This is the most radical procedure. It reduces the size of your upper stomach to a small pouch about the size of an egg. It’s the most complicated surgery but also the most effective, with weight loss up to 67 percent.
Adjustable gastric banding: This surgery is less commonly done than in the past. It involves putting a flexible silicone band around the top of the stomach to limit how much food you eat and make you feel full with less food. Average weight loss is 44 percent.
There are risks to these surgeries, and weight loss is disappointing for many. But in general, surgery is a far, far better option than the usual lifestyle struggles and diets that lead to maybe 10 to 20 percent weight loss. Many people who choose lifestyle changes and diets gain the weight back and still have diabetes and other diseases.
A recent five-year study comparing weight-loss surgery to lifestyle changes showed a clear winner in the surgery group. Far more people in this group lost significant weight, and many no longer needed insulin injections or other medicine when their diabetes went into remission.
If you are in a high-risk category, I seriously hope you make an appointment with your local bariatric surgery team to just discuss your options. If you're in the Swedish system here in the Seattle area, you can sign up for a weight-loss seminar. Call 206-215-2090 or email email@example.com and hear them out.
Who should consider bariatric surgery? The current recommendations are:
- Everyone -- and I mean everyone -- with a body mass index, or BMI, over 40, even without any other medical conditions.
- Anyone with a BMI of 30 to 40 and conditions such as diabetes, high blood pressure, high cholesterol, sleep apnea or severe arthritis.
A body mass index over 25 is overweight and over 30 is obese. Insurance companies usually will cover surgery if your BMI is over 35. Use this calculator
to determine your BMI.
My second piece of advice, perhaps even more controversial among physicians, is to try prescription medicine. There now are four prescriptions and one over-the-counter supplement that the U.S. Food and Drug Administration has approved for weight loss. These expanding choices are encouraging for family physicians on the front lines.
Most of the medicines work by decreasing feelings of hunger. All have side effects, and weight loss varies from 7 to 12 percent on average, depending on the medicine. Another caveat: People often regain weight after they stop taking medication.
But since even a 5 percent reduction in weight can greatly help reduce risks for diabetes, heart disease and arthritis, I think medication is definitely worth considering. I'm using more of these in my practice, and I strongly suggest interested people (and doctors) read the 2016 meta-analysis in JAMA comparing these medicines.
The take-away from the JAMA review is as follows:
- Phentermine/topiramate (Qsymia) is the most effective medication for weight loss, with side effects in the middle of the pack. This medicine is currently my first choice for many. But one side effect is severe: birth defects. All younger women on this medication must take birth control and get monthly pregnancy tests.
- The combo medicine naltrexone/bupropion (Contrave) was less effective than Qsymia, with more side effects. There’s also some debate about its safety if taken by people with heart disease.
- The OTC supplement orlistat (Xenical/Alli) is the least effective, but it has fewer severe side effects (stomach issues) and is the only medicine available without a prescription. Taken with each meal, it reduces fat absorption.
- The diabetes medicine liraglutide (Saxenda) is the second-most effective for weight loss. It has the most side effects, but it’s certainly a great option for people who have Type 2 diabetes.
- Lorcaserin (Belviq) has the least side effects but was second-to-last in effectiveness.
Who's a candidate for these medicines? The FDA says anyone with a BMI over 30, regardless of any conditions, and those with a BMI of 27 to 30 with risks of disease (the usual ones mentioned above). The goal would be to lose 5 percent of your weight over three months. If you do, great! Keep going!
Hopefully your insurance will cover the cost of prescription medication; many plans do not. (Note to doctors: It’s much cheaper to order the combination medicines Contrave and Qsymia separately, as two prescriptions).
I should also mention metformin, a common prescription medicine for Type 2 diabetes that has the great side effect of weight loss. Studies have shown overall weight loss to be less than 5 percent, and the FDA hasn’t approved metformin for shedding pounds. But it's still a fantastic first choice for people who are prediabetic and overweight.
And now we arrive at the third thorny issue: diets. There's so much confusion about diets right now that I’d like to simplify this issue by saying that it's not so much what you eat, but how much you eat. In other words, calorie restriction is key. If you want to lose a pound a week, you need to eliminate 500 calories each day. This is basic biochemistry. Check out your caloric needs with this weight-loss calculator.
If you can restrict calories daily, especially by cutting back on simple carbs, great! Keep going!
There's also another diet option you may have heard about. It’s alled intermittent energy restriction, also known as IER or the 5:2 diet. This diet involves eating normally five days a week and fasting for two days. IER has been trendy since 2013, with a BBC documentary, best-selling book and a British study about this regimen. According to the study, cutting calories (especially carbs) twice a week has similar or better results for reducing insulin resistance and losing weight than restricting calories daily.
When we fast, even if only for 12 to 16 hours (no food between dinner and lunch the next day), insulin resistance falls and fat starts to get reabsorbed. A recent review of all IER studies showed the evidence for this diet is promising, but it’s still premature to endorse it. There’s more to learn about which fasting patterns are ideal and whether there are any long-term side effects. Also, people who aren't overweight and try this diet actually experience more side effects than benefits.
Otherwise, in terms of diets, it's just overwhelming out there for people searching for the "right one." An excellent review article this year does detail quite convincing evidence that a low-carb, high-fat Atkins-style diet not only reduces feelings of hunger, it eases insulin resistance, improves cardiac markers and leads to weight loss. The DASH diet really does help to lower blood pressure and weight, and the Mediterranean diet also seems to help with heart disease and some weight loss.
But again, when it comes to dieting, the focus should be on food quantity, not food categories. It's simple biochemistry. You have to take in less energy to lose weight. Or you could increase your energy output, which leads us to:
For decades, the usual medical mantra has been: Get 150 minutes a week of moderate exercise. But that hasn't really translated into any meaningful changes in the health of many Americans, has it? So here's where another trendy (uh oh) regimen is gaining popularity, mostly because growing research on it is impressive. It's called high intensity interval training, or HIIT.
This workout entails exercising all out for 30 to 60 seconds, resting for a few seconds and then going all out again. You do this for 15 minutes tops, twice a week (typically). Check out an example in the image below from a New York Times article about a seven-minute workout. This HIIT routine is great because it requires zero fancy equipment, and you can do it anywhere. The Times also has an online workout app.
Supplements, herbals and diet
This topic is actually less controversial for me, mostly because there's an easy answer: There’s almost no hard evidence that supplements and herbals will help you lose weight. I'm not confident enough about recommending any of the trendy ones, and that includes CLA, chromium, 5-HTP and garcinia.
I'm sure many of you are already taking some of these. You're welcome to read the evidence, including some excellent supplement reviews by the Natural Medicines Database, Consumer Lab’s Encyclopedia of Natural & Alternative Treatments, The Cochrane Library, and the National Center for Complementary and Integrative Health.
Personally, I'd much rather have my patients focus on calorie restriction. I'd also rather give them one of the prescription medicines I’ve discussed; there’s more evidence of their effectiveness than there is for any supplement.
If you must choose a supplement, try the OTC orlistat, mentioned above. You also could consider soluble fiber such as blond psyllium. In fact, it's now recommended that people who take orlistat also take blond psyllium to prevent some of the unfortunate gastric side effects of orlistat.
Blond psyllium is used mainly for constipation, but it also can help lower cholesterol, control diabetes a tiny bit and aid a bit with weight loss. Taken with meals, orlistat and blond psyllium reduce fat absorption.
Yogurt is one of my favorite food recommendations. Not only does it contain probiotics, which help our microbiome and immune system, the literature shows that yogurt helps manage weight loss and waist circumference. I actually prefer higher-fat yogurt to low-fat versions. Adding fresh fruit to non-sweetened yogurt is a great way to start your day. Or add a pack of instant oatmeal microwaved with soy milk for a healthy and filling breakfast.
Here are some simple things we can all do to lose or maintain our weight.
Did you know that sitting all day at work is harmful to your health? Recent data, including a 2015 meta analysis of sedentary lifestyles, show that the more you sit, the higher your risks for heart disease, obesity, diabetes and lower longevity. I just ordered a standing desk for my office!
Use smaller plates
Americans definitely have suffered "portion distortion" over the years as sizes for all types of tableware creep up and up. Remember how soda machines used to carry 12-ounce cans? Now they sell 20-ounce bottles. How about a small popcorn at the movies? If we can't control these external factors, at least at home we can control portion size. One step is to replace all of your dinner plates with appetizer or salad plates. Recent studies, including a 2016 meta-analysis, show that when people switch to smaller plates, they actually eat less. How easy is that?
Keeping it off
It's actually not super hard to lose weight -- it's keeping it off that's the problem for most. Unfortunately, that's normal. The "hunger hormones" ghrelin and leptin reset to a new balance when we gain weight. But if we lose weight, they don’t reset as readily. Getting a good night's sleep can help with this rebalancing, but your hormones can continue to send hunger signals, compelling us to eat more than we should. Eating healthy carbs, fiber, yogurt and protein can help control hunger pangs.
And for those who have a BMI over 35 or 40, gastric bypass surgery can actually ease feelings of hunger permanently. How? Removing the top of the stomach in these surgeries removes the stomach tissue that secretes grehlin; less grehlin = fewer hunger signals = less eating = weight loss. That's another important reason why I urge people to consider weight-loss surgery.
My bottom line
After writing this article, I personally feel much more empowered as a doctor to help my patients lose weight. There are a lot more options than I had realized, and I'm definitely giving all of my overweight patients this article. I look forward to helping them lose weight in a healthy and permanent way. And hopefully I've helped you as well!