Treatment for obesity

A medical doctor will likely recommend what he or she feels is most beneficial based on the nature of a person’s overall physical condition. The more health concerns that apply, the more medical and / or specialist attention may be frequently required.

Treatment focussed on two primary objectives:

• Determine the best way/s to achieve a healthy weight
• Develop means that maintain a healthy weight

If no major health conditions are a factor, a doctor may wish to work with a person to periodically monitor their condition during their weight loss journey, ensuring that all vitals are functioning as they should and no further problems develop. If medications are required, monitoring will also be important. A doctor may also recommend others to join ‘the team’ for the journey, such as a dietician, councillor or therapist. In extreme circumstances, weight loss surgery may come up for discussion.

The physical benefits of getting to, and maintaining a healthy weight will be one of the primary areas of discussion when it comes to implementing a treatment plan. All of which are essential for healthy living and are achievable. Key benefits include:

• Improved energy levels and the ability to participate in more types of activity
• Fewer muscle aches and joint pains
• Improved heart function and reduced strain on the circulatory system and risk of heart disease
• Improved blood pressure levels and the regulation of bodily fluids
• Reduced risk of diabetes, affecting blood triglycerides and blood glucose levels
• Improved sleeping habits
• Decreased risk of cancer

1. Lifestyle and behavioural changes

One of the first steps which may be integrated into any medical treatment are adjustments to a person’s lifestyle. If a person can start and maintain a 3% to 5% weight loss (at the very least), they can achieve clinically meaningful improvements that lower their risk of developing serious conditions such as high blood pressure, diabetes and heart disease. Even greater weight loss achievements further improve blood pressure and cholesterol levels.

Forming a healthcare team is one way to achieve weight loss success. Obese individuals stand to gain far more by working with a team that can best take care of their condition in their quest to achieve significant weight loss and a healthier physical state, than going it alone. Structured eating plans with healthier choices and exercise regimes that help to build strength and endurance, and improve metabolism can make a significant difference.

• Diet: Calorie control and healthier choices implemented in a slow and steady manner is considered the safest way to lose excess fat and maintain a healthy weight (in the long-run). Drastic or unrealistic changes to a diet are not an effective long-term solution. Many diet programmes for long-term weight loss focus on an initial 6-month weight loss goal, followed by a year-long maintenance phase (gradual weight loss) as a means to further boost long-term success. Healthier eating choices include consuming more plant-based foods, whole-grain carbohydrates, lean protein, low-fat dairy, small amounts of heart-healthy fats and limited sugar and salt. Fad or crash diets and quick fixes are not the best solutions for weight loss, especially for those in the obese category.
• Physical activity: As with eating changes, physical activity (aerobic exercise) is critical for weight loss and healthy weight management. If a person is able to maintain a steady amount of weight loss over a year, are generally able to do so with the help of regular exercise. At least 150 minutes of moderate intensity physical activity (spread out over at least 3 days) will help to prevent further weight gain and maintain a modest amount of excess loss. Once this becomes achievable and a person wishes to lose more weight, increasing weekly minutes to 300 can prove effective. It’s important to make increases gradually and build strength, fitness and endurance. The important thing is to keep moving. The more a person moves, the more calories can be burned and weight can be lost.

Obesity is not just a physical condition. A person’s mental and emotional state have a significant impact on a person’s wellbeing too, and require just as much attention and care as the physical side of things. Counselling and support is an important part of treatment. Much of the adjustments required involve behavioural changes and these are considerably influenced by a person’s mental and emotional state. Support in this area can help to identify unhealthy triggers and provide coping measures that address the source of adverse behaviours.

2. Medications for weight loss

Once at the stage of obesity, often, lifestyle changes alone may not be sufficient to simple lose weight. Prescription medications for weight loss are available to be taken in addition to healthier lifestyle choices (diet and exercise). Medications should not be used in place of a good diet and exercise regime. A doctor will consider recommending medications if lifestyle adjustments are not showing a marked improvement or if a person has obesity-related health problems and a high BMI.

Prescription medications can help things along by preventing the absorption of fat and suppressing appetite, but there are side effects. All prescription medications will require periodic check-ups to ensure that a person is at their most comfortable taking the drug and that no adverse reactions are occurring, especially if taken in combination with others. Some unpleasant side-effects include frequent or oily bowel movements, increased bowel urgency or gas.

Some of the most common prescription medications are:

• Orlistat (Xenical): Blocks the body from absorbing about a third of all fatty foods consumed. Side-effects are generally mild at the start of dosages and include flatulence, abdominal cramping, increased frequency of bowel movements, a leaking oily stool, and problems controlling bowel movements. A change to a low-fat diet is recommended before taking this medication, as well as incorporating a multivitamin into a daily routine (2 hours before or after taking the drug). The medication may be used long-term, accompanied by frequent medical check-ups.
• Contrave: An extended-release formula, this medication combines naltrexone and bupropion (FDA-approved medications). Independently, naltrexone is commonly prescribed to treat opioid or alcohol dependence, and bupropion to treat depression and smoking habits. Common side-effects of the combination drug include headaches, nausea, vomiting, constipation, insomnia, diarrhoea, dizziness and dry mouth. The medication does have a warning for neuropsychiatric problems and an increased risk for suicidal thoughts. The drug is high risk for those who have problems with seizures, blood pressure and heart rate. The FDA recommends that if a person is not able to lose 5% of their body fat within 12 weeks, medication use should be discontinued.
• Belviq: An appetite suppressant. Non-diabetics commonly experience headaches, nausea, dizziness, dry mouth, fatigue and constipation as side-effects while on this drug. Those with diabetes may experience hypoglycaemia (low blood sugar), headaches, fatigue, a cough and back pain. Caution should be taken for those taking certain medications used to treat depression. A doctor may not recommend this medication for women who are planning to become pregnant or who are already. The FDA recommends that if a person is not able to lose 5% of their body fat within 12 weeks, medication use should be discontinued.
• Other appetite suppressants include: Saxenda (mimics the intestinal hormone and vagus nerve functions that signal fullness in the stomach), Qsymia (combines phentermine and topiramate which helps burn more calories and leaves a person feeling satiated) and Phentermine (also known as Adipex or Suprenza, is only prescribed for short term use due to a high risk of dependency and the nature of side-effects).

3. Weight loss surgery (bariatric surgery)

Surgery options are also available to help a person better control the amounts of food that can comfortably be eaten or prevent a certain amount of food or calorie absorption.

A doctor (or bariatric surgeon) will not usually recommend surgery outright. There are serious risks associated with surgical intervention as a means to achieving weight loss. Surgery is not a weight loss cure and cannot be considered a quick fix. To be considered a surgery candidate, a doctor will ensure that very specific requirements are met beforehand, often including a serious commitment from an overweight or obese individual to adhere to lifelong eating and exercise regimes. Following surgery, a person can run serious risks of falling ill and experiencing health complications if they attempt to return to their previous lifestyle habits.

A doctor will assess benefits over risks in order to make a decision regarding surgery as an option. A candidate will more often than not need to have a BMI of at least 40 (teenagers may be considered if their BMI is over 35) in combination with other serious obesity-related medical issues or conditions. There is also a certain amount of weight (15 to 30 pounds or 6 to 14 kilograms) which will be required to be lost before it is deemed safe to perform surgery. Counselling is also a requirement for any candidate ahead of a surgical procedure. Surgery is a serious consideration and needs to be treated as such by both the medical professionals involved as well as the candidate.

Smokers will be asked to discontinue completely as this can result in post-surgery complications, such as pneumonia. A doctor may also request that a candidate consult with a nutritionist and start making a change to eating patterns and specifically portions, for a set time prior to surgery. Many find that this helps a candidate adapt a little easier to eating smaller portions, slowing down when eating and becoming more aware of the nutritional value of foods consumed.

Common surgery options include:

• Gastric bypass (or Roux-en-Y / RYGB): A small pouch (i.e. portion of the stomach) is created at the top of the stomach, which connects to the small intestine (a surgeon divides the stomach into one small pouch and another larger one). A surgeon disconnects the first portion of the small intestine (duodenum) from the larger portion of the stomach and then connect the smaller pouch to the jejunum portion further down the small intestine. Sometimes referred to as ‘stomach stapling’, this allows for food and liquid to be directed straight to the smaller pouch, passing through the jejunum, bypassing the duodenum and remainder of the stomach. A smaller amount of food can thus be held in this smaller pouch, and consequently ‘forces’ a person to develop the habit of eating less than they were before, as well as curbing the absorption of some calories and nutrients. The procedure is often done laparoscopically involving several small incisions. A surgeon will use a laparoscope (small camera device) to perform the procedure through the incisions as a way of ‘seeing inside the body’. A mini-gastric bypass is also an option done through a laparoscope. The procedure effectively creates a new size stomach which restricts the amount of food that may be digested. Sometimes laparoscopic methods are not possible. In this instance, larger incisions are made in the middle of the abdomen (laparotomy).
• Gastric sleeve (sleeve gastrectomy): This procedure involves removing part of a person’s stomach (more than half) and can also be performed laparoscopically. A thin, vertical or narrow ‘sleeve’ (tube-shape) remains of the upper stomach. The surgery effectively curbs the ‘hunger hormone’ ghrelin, which also suppresses appetite enough to promote smaller portions being consumed.
• Laparoscopic adjustable gastric banding (LAGB or lap band surgery): This surgery is less invasive. The procedure uses a silicone band (or ring) to separate the stomach, effectively creating ‘two pouches’. The silicone band is placed around the upper stomach and the tightness adjusted with injections of saline filling the band (to loosen, the saline with be extracted). Once the surgeon is happy with the size, a person’s small incisions are closed up for recovery. Care is taken to ensure that the band is not too tight as this will cause side-effects, nutritional problems and complications. If necessary, the tightened bands can be loosened. The tighter the band, the more the stomach shrinks. The procedure results in less dramatic weight loss than a gastric bypass, but is still a successful surgery.
• Biliopancreatic diversion (with duodenal switch): This procedure is similar to that of a RYGB. The small pouch created is connected to a portion of the small intestine that is further down than the jejunum, known as the ileum. This effectively means that more of the small intestine is bypassed and a person absorbs even fewer calories, running the risk of not being able to get enough nutrients (vitamins and minerals) in the body. Nutritional problems are thus a risk of this procedure and can be a more complex surgery to perform. If performed with a duodenal switch, a gastric sleeve is used to bypass most of the small intestine.

Another potential option is…

• An electric implant (Maestro Rechargeable System): Similar to a pacemaker, this implant works by delivering electrical pulses to the vagus nerve between the brain and the stomach (which is responsible for signalling stomach fullness to the brain). The device is surgically implanted in a person’s abdomen and can be adjusted using a remote control.

What to expect following surgery

A hospital stay of 2 to 3 days is normally required to monitor a person’s adjustment following surgery, prevent infection or adverse complications (such as digestive problems, internal bleeding or ulcers). Rare complications that may be life-threatening can include pulmonary embolism (blood clots), leakage in the intestinal surgical connections, a heart attack, or severe bleeding (visible in the stools or faeces) and wound infection.

The majority of candidates may experience side-effects of nausea, vomiting, diarrhoea, abdominal bloating, flatulence (increased gas), dizziness or excessive sweating.

Normally, recovery for a gastric banding (less complex procedure) takes around 1 week. A gastric bypass can take about 4 weeks for a person to recover. A person may generally return to normal activity within 2 to 3 weeks following surgery. Weight loss is often quite dramatic following gastric bypass surgery, with many losing between 50% and 70% of their excess weight within 18 to 24 months (a gastric sleeve procedure can accomplish about a 40% loss of excess weight). This has dramatic effects on a person’s overall health and can sometimes reduce serious health complication risk virtually to zero (with some improvements becoming evident in the short term and others over a longer period of time). Few ever regain lost weight.

In the short-term, a person may wish to have sagging skin surgically removed, as well as take supplements to ensure that nutritional deficiency doesn’t occur. Following weight loss surgery, it is fairly common for the body to struggle to absorb iron, vitamin B-12, folate, vitamin D and calcium effectively.

Weight loss surgery may result in long-term problems. These risks will have been discussed in full prior to surgery. Common problems include:

• ‘Dumping syndrome’: Often experienced in gastric bypass candidates, whereby food and liquid moves through the small intestine too quickly. A person will experience nausea, diarrhoea, feeling faint, and sweating following a meal. High sugar foods and beverages, such as fruit juices and sodas may also cause a person to feel very weak, but can be replaced with those higher in fibre content to curb the side-effect.
• Gallstones: When a person loses a substantial amount of excess body fat in a short space of time, gallstones can occur. Supplemental bile salts may be recommended before surgery as a foreseeable measure to try and curb this potential occurrence. These will be taken for 6 months following surgery.
• Constipation: A surgeon may recommend that a person avoids granular fibre following surgery which can result in bowel obstructions.

Women of reproductive age who undergo weight loss surgery will also have to have a serious conversation with their doctor about potential future pregnancies following their procedure. A doctor will strongly advise that a woman takes measures to avoid falling pregnant until such time as it is medical deemed safe and her weight is stable. Rapid weight loss and nutritional problems or deficiencies can have adverse effects on a developing baby and cause congenital problems, as well as cause a woman to become anaemic.

Lifestyle changes after surgery

Surgery forms just one part of a dramatic lifestyle change. The rest is up to the candidate, once recovered from surgery. Changes which will help to ensure the best results following surgery include:

• Consuming smaller, frequent meals: Having surgery to combat excess body fat effectively means the end of binge-eating habits. And for good reason. A smaller stomach cannot hold as much, making larger meals problematic.
• Making a commitment to a healthier diet: Choices will now need to revolve around more nutritious options. For those who have difficulty sticking to a new diet, a nutritionist can provide a healthy eating plan. This will ensure balance and stability when it comes to daily nutrition (yo-yo dieting will not be comfortable or advisable).
• Maintaining a healthy exercise programme: Keeping weight off is somewhat easier than working to lose it. Exercise post-surgery and initial weight loss is often a lot easier on the body, especially where a person was affected by joint aches and pain before. There are plenty of exercise activities that a person need not develop a grudge against doing. Many activities can be enjoyable as much as beneficial for the body. Those that a person finds they most enjoy doing generally maintain regular participation, and as such, offer great benefits.