It takes a long time to gain weight, so it makes sense that it can take a long time to lose it. If you have tried to lose weight yourself, you know how hard it is.
There are some key ingredients for a weight loss plan to be successful, including:
- The initial weight loss is rapid.
- That’s surprising isn’t it?
- Using a meal-replacement or medication to kick start the weight loss may be useful. These need to continue to maintain the weight loss long term.
- Setting a realistic goal for the weight loss.
- Work with your patient to find an agreed target and timeframe.
- Is it 5-10% weight loss?
- Is it to fit into a clothing size?
- Measuring the weight loss regularly.
- Waist circumference is better than weight because it measures visceral fat, which is the cause of disease.
- Regular measurement keeps your patient on target, motivated and accountable.
- Remember to celebrate the wins, and bounce back from inevitable disappointments.
- Psychosocial support and regular follow-up.
- This could be from you, a psychologist or supportive family member.
- If depression drives eating behaviour, then this will be very important.
- Regular visits maintain the momentum and focus.
- Education around healthy habits.
- Although the weight loss is the motivator, adopting healthy habits should really be the focus – including sleep hygiene, stress management, and exercise.
- Maintaining the behaviour changes is the only way to sustain the weight loss long term.
- It could involve a dietitian, exercise physiologist or psychologist.
- Your patient may prefer books, YouTube videos or apps.
- Enough sleep.
- Sleep deprivation makes any weight loss strategy fail.
- Aim for 7 – 8 hours of sleep at night.
- Improve sleep hygiene, treat sleep apnoea and consider Melatonin if needed.
- Foods that are associated with lower or stable weight in the long term.
- Large observational studies have identified the foods that are associated with a lower BMI.
- Yoghurt, vegetables, nuts, egg.
- Similar studies have shown that these foods are associated with long term obesity.
- Soft drinks, sugar, potatoes and potato chips, cured meats.
Weight loss of 5-10% is enough
Most patients set themselves unrealistic weight loss goals and then give up. The good news is that health comes from far less weight loss. To see improvements in blood pressure, glucose levels and cholesterol, only 5 – 10% of weight needs to be lost. So, your 120kg patient should be aiming for 6 – 12 kg of weight loss to see the health benefits.
The simple message of “Eat less and exercise more” doesn’t work. We have all said it, but we have seen in our patients that it doesn’t work. While the textbooks and guidelines continue to recommend this, it fails to recognise and work with the hormones that suppress hunger and regulate fat deposition.
The hormones that make your patient hungry are insulin and ghrelin. The hormone that drives fat deposition is insulin.
Medications that can assist in weight loss work best when combined with the lifestyle strategies and psychological support.
Bariatric surgery is an effective option to achieve weight loss, reduce medication requirements for diabetes and blood pressure control. Of all the weight loss strategies, surgery has the highest rate of success. The effect of bariatric surgery is to change the dynamics of appetite-regulating hormones in the stomach and small intestine.
- Ghrelin is the most powerful hunger-stimulating hormone, and it is removed when the fundus of the stomach is removed or bypassed.
- The incretin hormones (GLP-1 and GIP) are appetite suppressing hormones and they respond to food when it hits the jejunum. Bariatric surgery means that food stimulates these hormones a lot earlier than normal, so appetite is suppressed soon after eating.
The choice of surgery will depend on your patients’ preference, your local surgical expertise and clinical decision making.
Bariatric surgery isn’t for everyone. People with underlying psychiatric disorders or addictions do not respond well. If your patient wants to proceed with surgery, these issues should be addressed and resolved before referring to the surgeon.
The factors that would contraindicate bariatric surgery include:
- Psychiatric disorders.
- Significant eating disorder.
- Ongoing drug or alcohol addiction.
- Lack of commitment to lifelong behaviour change.
- Significant medical comorbidities eg. active cancer.