Last partial update: July 2016 - Please read disclaimer before proceeding

 

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Problems with common attitudes to weight loss

For a long period society has had simplistic and often misguided attitudes towards obesity and weight loss. They have been centered around blaming obesity on laziness or gluttony and assumed everyone could be slim with a disciplined approach to diet and exercise. It also assumed that being thin optimizes health and happiness. The problems with these attitudes are they do not give a real understanding of the complex nature of factors that both cause obesity and affect its treatment, and they do not distinguish between weight and health.

People wishing to lose weight need to focus on attainable and sustainable solutions that will deliver a comfortable weight and improved health. Such solutions will need to encompass behavioural change in both diet and exercise.

Weigh issues are unique to each individual

Central to this approach is assesment of each individual's weigh issues and the formulation of a program that is best for that person. This requires the help of a trained dietitian. Many eating problems are psychologically / emotionally based and often require the help of psychological techniques such as cognitive behavioural therapy to fix.

Concentrating on weight loss rather than on achievable behavioural change is not helpful
Concentrating on changing eating and exercise behaviour is a more successful approach than concentrating on short-term weight loss. These behavioural changes should be people’s main long-term priorities.

The behavioural goals in weight-loss strategies should focus on what people can realistically achieve and sustain. Almost all overweight people have tried to lose weight on numerous occasions and failed. The main reasons for this are that they:

This starts the 'unsuccessful weight loss cycle’, where repeated failure leads to increasing disollusionment and lower self esteme, making future success very unlikely. Repeated weight loss followed by weight gain has also been associated with generally poorer health and can cause a reduction in lean body mass (i.e. less muscle), thus making future weight gain more likely.

It is probably best not to have any definite weight loss goal at all and just concentrate on strategies to improve health. (Having said this, people who have lost weight shouldy regularly monitor their weight as this has been shown to help maintain weight loss.)

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Adopting healthy attitudes to modifying eating behaviours

Positive attitude towards diet and body

Foods should not be categorised as ‘bad or good’, as this can increase feelings of guilt and failure. It is better to categorise foods as being ‘everyday’ or ‘sometimes’ foods. People should also not focus exclusively on the negative side of their body image. They should ‘accept’ their body while they are trying to change it. A good method is to write down body attributes, for example having good eyesight or musical ability.

Weight loss through dietary change is slow

As mentioned in the previous section, healthy weight loss is almost always a slow process. Dramatic dietary changes that are aimed at achieving quick weight loss are usually impossible to maintain in the long run and failure, which usually occurs within 12 months, just reduces self confidence and the likelihood of future success.

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Summary of treatment options

Treating obesity requires a multifaceted approach and it is important to get help from a GP or dietitian or both to help with coordinating the different processes involved. These are summarized below and always need to include diet and physical activity modification. In some people, medication and surgery are options that need to be considered.  

1.   Long term modification of food intake

This is obviously the cornerstone of treatment and the concepts involved are examined in a seprate section -

Long term modification of food intake. (Click here to access.)

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2.   Increasing physical activity

After ensuring that they do not smoke, this is the most important thing that most Australians need to do to improve their health. It has been shown that 30 per cent of adult Australians engage in no exercise at all and 54 per cent do not do enough to gain any benefit.
Exercise is an integral part of any weight loss program and without it, successful long-term weight loss, the only worthwhile kind, is very difficult. The topic of physical activity is dealt with in detail in the section 'Physical inactivity'. Click here to access section 'Physical inactivity'

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3.   Medication to reduce weight

At present there are two drugs that have a role in the treatment of obesity, orlistat and sibutramine. (See boxed section below.) These drugs are expensive and are generally only used for the treatment of obese individuals (i.e. those with a BMI greater than 30) or in people who are overweight (i.e. a BMI between 27 and 30) with a significantly increased risk of cardiovascular disease, especially if this increased risk is due to the metabolic consequences of being overweight i.e. high blood pressure and insulin resistance / diabetes.

Where depression may be a significant contributing factor to obesity, treatment for the depression is needed and this will sometimes include medication.

When making decisions about medication to treat other conditions, such as diabetes and hypertension, it is important to choose, where appropriate, medications that do not make an existing obesity problem worse.

Many other ‘weight-control’ medications have been used in the past but most had numerous side effects, were addictive in nature, or were ineffective in the long term. Appetite suppressants are especially bad as they are addictive and cause agitation and insomnia. Other drugs that can cause weight loss are thyroxine, diuretics and laxatives. None of these drugs should be used for achieving weight loss.

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Medications for treating obesity

Orlistat   
This drug inhibits the lipase enzymes in the gastrointestinal tract that help break down dietary triglycerides to fat acids. Dietary triglycerides are too large to be absorbed and the use of orlistat thus results in about 30 per cent of consumed triglycerides remaining unchanged in the bowel and eventually lost as fat in the bowel motion.

Overall orlistat has been shown to achieve a slightly higher weight loss than with diet alone. Weight loss is usually slow with losses of less than 1 kg a month. Trials have shown that diet plus orlistat can provide a five to ten per cent weight loss after 1 year and this degree of weight loss does help in reducing cardiovascular risk factors, such as hypertension and diabetes. Orlistat can reduce LDL cholesterol by about 8 per cent.

It is prescribed for those with a BMI  greater than 30 or for those with a BMI greater than 27 plus other risk factors for vascular disease such as hypertension, diabetes etc. Side effects are usually mild, but do occur in many patients. They are mostly due to unabsorbed fat being passed in the bowel motions, which causes oily spotting, flatus with discharge, faecal urgency and occasionally faecal incontinence. The best way to minimise these side effects is to keep to a low fat diet (less than 50 grams of fat per day) and the prospect of mild incontinence is usually a good incentive for people taking the drug to keep to such a diet.

Two year studies have shown that the drug also causes a reduction in the absorption of fat soluble vitamins, including vitamins A, D, E & K. The blood levels of these vitamins did not, however, fall below normal ranges. Whether longer term therapy causes a greater problem needs further investigation. People with nutritional vitamin deficiencies may need vitamin supplements which should be taken at least two hours after their Orlistat dose.

Interactions with other drugs do occur. These need to be discussed with a medical practitioner. Ninety-seven per cent of the drug is not absorbed and is excreted in the faeces.

Liraglutide (Saxenda)
Liraglutide suppresses appetitie and delays food emptying from the stomach.

Sibutramine (Reductil)
Sibutramine is a new drug and is a member of serotonin and noradrenalin uptake inhibitor group of drugs that are more commonly used for the treatment of depression. It acts by reducing hunger and reducing the decline in energy expenditure (resting metabolic rate) that occurs with weight loss. It can achieve a weight loss of five to ten per cent, most of which occurs in the first six months of treatment. It can also give improvements in blood lipids and is used in people with a BMI of over 30 or over 27 if they have other vascular disease risk factors. Its side effects include dry mouth, insomnia, headache and constipation. A slight rise in blood pressure also occurs and blood pressure needs to be carefully monitored, especially if the person is at increased risk of cardiovasciular disease, as many obese people are.

Unfortunately, sibutramine’s effects only occur while it is being consumed and weight loses are often regained once it is stopped. Thus it is often used for a longer period (up to two years). It unfortunately is quite expensive.

 

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4.   Other weight loss strategies for the very obese

Very obese people have additional problems in losing weight, such as their size making increasing physical activity difficult, and they often need special approaches to their management.

Special very low calorie diets: These diets are an option for people who have properly tried a low-fat diet and been unsuccessful, for people requiring rapid weight loss prior to essential surgery, and for those who are so obese they are unable to exercise. They should be attempted only under proper medical supervision. Side effects include constipation, gallstones, hunger, hypotension, gout and low blood potassium.

Surgery: This option is used only in the morbidly obese (i.e. those with a BMI greater than 40) where all else has failed. It can be permanent (gastric stapling) or temporary (a removable gastric band) and has a success rate of 30 to 50 per cent. Complications include surgical problems as well as long-term nausea, vitamin deficiencies, constipation, and the possibility of obstruction. Surgical complications are more common in very obese people. (They can be reduced by performing the procedure by laparoscopy.)

Another option is the use of an intra-gastric balloon. This is placed in the stomach and reduces the amount of space for food; and thus the amount of food eaten.

Surgery should not be viewed, however, as an easy fix to the problem. As with all treatments for obesity, learning to eat better and exercise more is the key to final success.

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5.  Treating associated conditions

Overweight people often have illnesses that can exacerbate the medical problems that their obesity causes. Important conditions include the following:

All these problems need to be looked for and treated appropriately. Depression is also not uncommon in obese people and has been shown to significantly increase the risk of cardiovascular disease.

 

What are the secrets of maintaining significant weight loss?


A review of 4000 people* in the USA who have successfully lost weight (at an average of 33kg each) and kept it off (for an average of five years) found several factors that were common to the weight loss strategies of most individuals. These were as follows.

These last two factors are important in preventing regaining weight, the main problem for anyone seriously attempting weight loss. Another factor that has been shown to be helpful in this respect is group support. Many also watched less than 10 hours TV per week

(*These people were on a database called the National Weight Control Registry, operated by doctors at Brown University in Providence, Rhode Island, USA.)

 

 

A separate section examines the first treatment option mentioned above - 'Long term modification of food intake' (Click here to access)

 

Further information

Weight watchers
www.weightwatchers.com.au

Parents Jury
The Parents Jury is a web-based network of parents who wish to improve the food and physical activity environments for children in Australia
www.parentsjury.org.au

 

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