The New Year is here and so are the resolutions. Numero uno for many is weight loss. Getting back to the gym, and watching one's diet is the typical choice for many well-intentioned "resolutioners". But alas, we all fall back to our old ways, and the cycle continues.

So, what can one do to lose weight for good? Obviously, weight loss is a huge (no pun intended) market. Seems that everyone has an opinion or solution, including an overwhelming number of internet marketers and supplement salespersons.

With over 80% of the U.S. population either overweight or obese, it comes as no surprise that Americans are "hungry" for a weight loss solution that works. Clinical, proven, and effective are all desirable, but what does that mean?

Truthfully most weight loss programs and supplements do not result in sustained weight loss. In other words, they don't work long-term. Sure, one may lose weight initially, which is fine for a class reunion or a wedding, but maintaining weight loss is the problem.

The medical establishment pretty much continues to preach the simple concept that in order to lose weight "calories IN must be less than calories OUT (burned)”. Simple math. And truth be told, this adage has yet to be UNproven. Cirrus Medical Network (CirrusMED) physicians are well versed in the management of obesity and implementing online weight loss strategies.

So how does one make the equation work in their favor? And how does one sustain weight loss?

What are the barriers to weight loss?

The American way

Our access to food (until recently mostly calorie-laden) is ridiculously easy and effortless. Pressed for time our society expects on-demand food. Our patience is thinning just as our attention span wanes. Try finding something fresh, lean, and green that actually tastes good, is not that easy. We can't all afford a personal chef. Granted, the next generation will probably have figured out a better way and will demand it. Folks who grew up in the ’70s, '80s, and ’90s were subjected to all sorts of packaged so-called foods ( squirty cheese? really?). No wonder these folks complain of irritable bowel symptoms in record numbers...but that is a whole other blog post.

Consistency

Everyone has their thing. Their habit. Their addiction. Their thing that they can’t live without. Ask yourself, what is the first thing you do after you wake up? Smoke, sip coffee, check Facebook, exercise, shower? What item can you not leave home without, or what app on your phone could you not live without? What is it about human behavior that makes these actions or objects so consistent in our lives? Whatever it is, it is powerful. Finding a solution to weight loss may have to do with harnessing the power of consistency. Some call it determination or willpower. Some visualize a goal. Either way, getting from point A to B will require consistency, a habit so to speak.

Weight loss can only be sustained when one harnesses that same force that drives those habits that one cannot live without. Whether it’s running 3 miles a day, 30 minutes of P90x3, eating “lean & green”, walking the dog, or hitting the gym...make it “your thing”.

Emotion

We wouldn’t be human if we didn’t feel emotion. Stressed? Sure, everyone has some level of stress in their life. If not, they are lying. Stress can lead some to eat more, some to eat less. Ah, the “emotional eater”. We’ve heard it before, and it is real. Similarly, stress and fatigue send many workers right to the couch after work, plopped in front of the TV…” too tired to work out”. Thus, the futile cycle begins. Overworked, stressed, too tired to exercise, eat for comfort, feel crappy, sleep..repeat.

Along with stress, depression and anxiety affect appetite and overall motivation. We all know that exercise and eating right will help depression and anxiety, but how does one get over the hump? That is the question.

Genetics

Ok. This one isn’t fair. However, almost all medical conditions have some sort of genetic predisposition. If not, then it’s random “bad luck”. If your parents, or grandparents were obese, then you are more likely to be overweight or obese. Sucks right? Yep. We all know people who can eat at McDonald's 3-4x/week and not gain a pound, while others eat reasonable portions of healthy food yet seem to carry excess weight. The bottom line, obesity is “pleomorphic”. A lot of factors contribute, including your genetic makeup. Either way, if 10 things lead to overweight/obesity, know that you can modify 9/10 of them and make significant strides. That 1/10 factor is related to your parents we’ll just have to accept and move on.
What can you do to combat these 4 barriers to weight loss? How can you achieve sustainable weight loss? The answer is not “one-size-fits-all”. Rather, individualization of a weight loss program is paramount to success.

The Mindset

I helped one of my patients lose 100# merely with one sincere heartfelt one-on-one counseling session. This discussion triggered a conscious decision on his part to make changes in his lifestyle. No meds, no trainer, no fad diet. Just a reality check and an honest discussion. He found a way to avoid the temptations of the American way, the emotional pull of food, and made healthy choices, consistently. Seeing progress and getting feedback over time just fueled his fire to lose weight. I didn’t even have to tell him a specific weight goal. He knew what he had to do.

Unfortunately, for many, the “reality check” occurs after a traumatic event. Perhaps a friend, coworker, or relative suffers a major medical setback such as a stroke or heart attack? This prompts a visit to the doctor to get checked out for whatever condition they now fear they might have. Naturally, the doctor is thinking to himself “why now? you should have been thinking about this all along...healthy lifestyle, etc.”

Nobody wishes a traumatic event on anyone or their relative, but how can one leverage this type of force into a positive behavioral change without actually experiencing the trauma? For the gentleman above, I essentially made the possibility of morbidity (and mortality) real enough that it struck that same emotional nerve. Powerful, and once again..no meds needed.

Clearly, the power of mind-over-body is huge when it comes to weight loss. However, some people need something more tangible to achieve their weight loss goal.

How to achieve sustained weight loss

Traditional tools to lose weight including aerobic exercise (running, biking, treadmill, stairs, elliptical, and so on), and a low-calorie diet are the mainstay of weight loss programs.

Exercise

This is not rocket science. It is not the easiest or fastest way to lose pounds, but it sure does make one feel better. The endorphins released with exercise which explain the “runners high” are nature’s antidepressant. Stress seems to just melt away with exercise. Less stressed, less tempted to snack on poor quality foods, or gorge oneself with unhealthy portions. Win-win.

No rules. Just move. Too cold outside or hate going to the gym? Try yoga. You can work up a sweat in a 3’ x 7 ‘ space all while improving core strength and flexibility.

Diet

Nothing drums up more debate than a diet. If you have to buy a book to follow a diet, it probably is not going to work long-term. Atkins, Paleo, Gluten-free, Zone diets and so on all have some legitimacy in philosophy. “Fat burns in the flame of carbohydrate” was the mantra of the biochemistry ketosis lecture in medical school. Unprocessed/natural/organic foods are better for the digestive tract and less likely to result in fat buildup. However, the “American way”, consistency, and emotion altogether stack the odds of sticking to these diets almost nil.

Personally, the “intuitive” diet made popular by a Salt Lake doctor years ago made the most sense. Basically, listen to your body. Eat when you're hungry. Stop when you are full. Duh. So simple but yet hardly followed. The little voice of your mother saying “eat your whole plate before you are excused from the table” and the traditional 3 meals a day model of consumption that has been drilled into us and structured for us for life sure makes it tough to be intuitive.

“Lean and green” is also a reasonable way to go. Lean meats (fish, chicken), and leafy greens/vegetables (minus the fat-laden dressing). Another simple approach is the “no sugar, no flour (no rice)” diet, popularized by newspaper columnist Dr. Gott.

Ultimately, moderation wins. Like a drink on the weekend. Go for it. As long as it’s not a 12-pack of beer. Feel like chicken wings? Sure, go for it. But make your next meal a lean and green salad...or if you’re not hungry for 12 hours, then don’t eat.

Water is good. Soda, not so much. Make sure your balance is weighted toward water.

Medication

In the last few years, we have seen several new drugs approved for the treatment of chronic obesity and overweight. The FDA's acknowledgment of obesity as a disease may have something to do with this since there had been a 15-year or so gap since the last approved medication for weight loss. The idea is that targeting weight loss would result in fewer weight-related comorbidities such as hypertension, hyperlipidemia, and diabetes.

This makes sense. Why subject someone to 3 categories of medications when we can just use 1?

Phentermine and Phendimetrazine - cheap and fairly well tolerated. Only approved for short-term use (< 3 months). It is a scheduled medication that generally requires a hand-carried prescription. Stimulant/amphetamine-like medications may have adverse effects such as palpitations, anxiety, insomnia, dry mouth, and constipation.

Qsymia - a combination of phentermine and topiramate ER. Expensive but modestly effective and approved for long-term use. Side effects are minimal at lower doses. Expect about 10-12% weight loss from baseline, with most of it lost in the first 3 months. I’ve had some patients love it and lose a fair amount of weight. Others just simply can’t afford it or have intolerable side effects like paresthesias (tingling). Taste of things such as cola changes with this medicine, which is not necessarily a bad thing. Check https://qsymia.com/ for discount programs and more information.

Belviq - a unique medication that has affected a serotonin receptor in the brain, essentially altering hunger sensation, though the exact mechanism of action is unknown. It is also expensive and slightly less effective in a clinical trials than Qsymia. However, it may be considered in either Qysmia or Contrave and is not tolerated or contraindicated. See http://www.belviq.com/ for more information and discount programs.

Contrave- a combination of bupropion (generic for Wellbutrin) and naltrexone. Both bupropion and naltrexone have been around for years and are used for a variety of conditions including depression, smoking cessation, craving/impulsivity, and addiction. Surely clinicians have used the meds individually, off-label, over the years to indirectly help with weight Contrave is relatively new to the market as of this writing. The manufacturer came out of the gates with very aggressive pricing (very smart in my opinion) which may propel its use. One logistical advantage of Contrave is that it is not a scheduled medication. In other words, it can be called in directly to your pharmacy and refilled without a new signed prescription each time. Check out http://www.contrave.com/ for more information and discount programs.

GLP-1 agonists - GLP-1 Receptor Agonists Approved for Treating Obesity Liraglutide and semaglutide may be used together to treat obesity. They work by stimulating GLP-1 receptors in the brain, which helps reduce appetite and increase feelings of fullness. The drugs are injected once per day, usually subcutaneously. However, liraglutide is administered via injection while semaglutide is taken orally.

Both drugs are manufactured by Novo Nordisk A/S. The Food and Drug Administration (FDA) approved both products in 2013. In 2016, the FDA expanded the label for liraglutidine to include use as an adjunct to a reduced-caloric diet and increased physical activity for long-term weight loss. The FDA approved semaglutide in 2017.

Some people taking liraglutide with insulin may experience low blood sugar. You may want to check with your doctor if you have kidney disease, liver disease, heart failure, or a history of pancreatitis.

Semaglutide is associated with nausea, vomiting, diarrhea, and stomach pain. People with certain medical conditions, including ulcerative colitis, Crohn’s disease, and pancreatic cancer, are at greater risk of developing these side effects. Semaglutide is contraindicated in patients with hypersensitivity to human proteins.

Diabetes drugs in the GLP-1 agonists class are generally taken by a shot (injection) given daily or weekly and include:

• Dulaglutide (Trulicity) (weekly)
• Exenatide extended-release (Bydureon bcise) (weekly)
• Exenatide (Byetta) (twice daily)
• Semaglutide (Ozempic) (weekly)
• Liraglutide (Victoza, Saxenda) (daily)
• Lixisenatide (Adlyxin) (daily)
• Semaglutide (Wegovy, Ozempic injections; Rybelsus orally)

Tirzepatide (brand name Mounjaro) is a GIP/GLP-1 receptor agonist that has very promising results when used for treatment of obesity and overweight. It may be a little better tolerated than the standard GLP-1 agonists. 

Surgery

Always a last resort, but highly effective in the first 5 years, bariatric surgery can make a huge impact on the life of an obese patient, both good and bad. Metabolically, bariatric surgery can result in massive weight loss and discontinuation of all medications. Eradication of diabetes, high blood pressure and high cholesterol is very possible in the compliant bariatric patient. However, with a ying, there’s a yang. The downside are the lifelong needs for monitoring, vitamins, iron, and sometimes mental health needs. Changing one’s anatomy permanently is a big deal, despite what the surgeon may say...it has lifelong implications.

Conclusion

In summary, achieving longstanding weight loss is complex. Obesity causes are multifactorial and as such, the treatment options vary in both effectiveness and appeal. Individualization is key, just as much as moderation. Finding consistency and the mental fortitude is essential. Rather than waiting for a life event to trigger change in your lifestyle, find your inner alarm and awaken your mind to a new addiction.

For help with actionable steps to achieve weight loss and other healthy lifestyle choices, search for a CirrusMED physician offering weight loss and obesity management memberships. Our online weight loss program is personalized. Our doctors know you, and your medical history, and over time will tailor a program in line with your personality and disposition. Whether it is counseling, dietary advice, or medications, our goal is for you to sustain reasonable weight loss for the long haul, for your overall physical and mental well being.