Out with the Old: The New Era of Weight Management

For better or for worse, managing weight is a lifetime journey. Obesity Medicine is the specialty of diagnosing and managing the chronic condition of excess weight. While it is a relatively new specialty, there is a lot more known about energy regulation in humans. What we certainly know is that the old paradigm of dieting to lose weight most often leads to ineffective weight loss or to weight cycling, which is weight loss and then weight regain over and over again. Fortunately, in obesity medicine, the paradigm of weight management is similar to that of any other chronic condition which is managed over time. Unfortunately, most people do not have access to this type of care and even receive disinformation which can cause harm. Let’s look at how the current paradigm which reflects the current state of science looks at reducing weight and keeping it off. Keep in mind, research and science is a dynamic process, and constant re-evaluation is part of the scientific process.

Overweight/Obesity

The Old

In the old paradigm, it was thought that all humans would generally be at a normal weight naturally, unless there was an imbalance in the “calories in/calories out” equation.

The New

In the new paradigm, it is understood that about 80% of a person’s weight is determined by their genetics and environment, and a relatively small contribution comes from the minute to minute decisions and choices that are most often seen as determining a person’s weight. It is further understood that this weight set point is actively defended by many complex neurohormonal mechanisms which drive the weight back to a person’s “usual weight” if it deviates significantly.

Weight Loss

The Old

In the old paradigm, losing weight tended to be reducing calorie intake and increasing calorie output. The eating less part tended to focus on simply counting calories. The increased calories out tended to focus on aerobic exercise and burning calories during exercise.

The New

In the new paradigm, the initial evaluation before a weight loss program is prescribed includes diagnosing and treating underlying causes of excess weight, identifying and potentially removing any contributing causes of excess weight, diagnosing and treating conditions resulting from excess weight, and identifying the type of excess weight a person has. These crucial first steps are frequently skipped over in a non medical or non specialty approach and may lead to incomplete weight loss or increased risk with weight loss. During weight loss, in the new paradigm, a nutrition approach will typically include direction on macronutrient profile, nutrient timing, and circadian rhythms, rather than simply the number of calories. The “calories out” side of the equation will focus much more on activity than exercise and will incorporate research on the importance of resistance exercise and controlling the intensity of aerobic exercise to avoid impairing weight loss, excessive loss of lean body mass, and increasing hunger and fatigue.

Willpower

The Old

In the old paradigm, “willpower” was a nebulous mainstay of dieting. Somehow, it was perceived as a strength of character to be able to endure hunger for prolonged periods of time.

The New

In the new paradigm, it is recognized that complex neurochemicals regulate hunger, cravings, satiety and satiation, so that people experience these things differently. This is why some people forget to eat and others tend to plan their next meal.

Weight Maintenance

The Old

In the old paradigm, it naturally follows that once you lost weight, it would stay off as long as you ate reasonably and moved, or followed a healthy lifestyle like someone of your similar height and weight.

The New

With the new research, it is understood that something called “metabolic adaptation to weight loss” drives body weight back to its weight set point by reducing resting metabolic rate and increasing hunger and cravings. This means that if you follow a similar lifestyle to someone who is naturally at your same height and weight at your goal weight, you will gain weight while they stay the same weight. This means you have to consume not only fewer calories than you did before losing weight, but fewer than people naturally at your goal weight, all while usually being more hungry and having more cravings. Or, you have to burn more calories with more exercise, and it is usually both.

Weight Management Medications

The Old

Prior generations of weight loss medications were labeled to be taken for 12 weeks, and then stopped. They tended to be appetite suppressants and stimulants which helped people tolerate reduced calorie intake for a short period of time and still have energy to exercise to lose weight. It was then assumed the medications would be stopped and the weight would stay off by simply following a healthy lifestyle. This led to most people who were prescribed these regaining their weight, plus more, which led to the medications falling out of favor with most physicians and many of them will not prescribe them.

The New

The current generation of medications are called “anti obesity medications” instead of “weight loss medications” and are studied for 1 to 2 years before being FDA approved. Their labeling does not include a duration to be taken, and so they are consistent with medications for other chronic conditions such as high blood pressure or high cholesterol. The data on these medications shows the same thing: if the medication is stopped, the benefit goes away, and the weight loss curve returns to match that of a person losing weight without medication. To illustrate this, think of cholesterol medicine. They lower your cholesterol as long as you take them, but most people know that once you stop them, your cholesterol goes back up. Therefore, anti obesity medications are okay to take not only during weight loss, but to prevent weight regain, as they are treating the underlying, chronic condition of obesity and the metabolic adaptation to weight loss which occurs at your goal weight.

Goal Weight

The Old

In the old paradigm, people would look at their height and BMI and estimate their goal weight.

The New

In the new paradigm, weight loss targets are calculated as a percentage of total starting weight in medical weight loss or as a percentage of excess weight in surgical weight loss. For example, lifestyle modification is expected to lead to a 3- 5 % weight loss over the course of about six months. Intensive lifestyle modification, such as that with nutrition and exercise coaching, is expected to lead to about 6% weight loss. Medical weight loss including intensive behavioral therapy and pharmacotherapy and/or meal replacements is expected to lead to 15% or even 20% weight loss, in the same ballpark as some surgical procedures. This paradigm recognizes that it is a reduction in excess weight that leads to reduced health risks and that weight loss gets harder and harder as it goes.

Putting it all together. 

As you can see, the new paradigm of chronic weight management is much more complex than “eat less, move more.” Individual health factors mean that no two situations are the same. This is where your relationship with a physician trained and educated in Obesity Medicine comes in. Taking the first step can be the hardest. We’d love to hear from you, or see you again.

Take Back Your Weight Loss Curve,

Valerie Hope-Slocum Sutherland, MD