Let's Talk About Obesity Treatment
There are obesity treatments that can make losing weight a little less of a battle. They can add years to your life, too. by Leslie Goldman Health Writer
Google the words “obesity treatment,” and you’ll be rewarded with hundreds of millions of suggestions. (We’re not making this up—try it yourself!) With such an onslaught, it can be easy to think that they're all scams and just give up. But here's the thing: Among all those results, there are treatments that really can help you lose weight safely and live a healthier life. The trick is having enough info to know which ones deserve attention…and which are pointless and even dangerous. And that's where we come in. We've got the answers you need.
Our Pro Panel
We went to some of the nation's top experts on obesity to bring you the most up-to-date information possible.
Deborah Bade Horn, D.O.
Medical Director; Assistant Professor of Surgery
Center for Obesity Medicine & Metabolic Performance; University of Texas McGovern Medical School
Donna H. Ryan, M.D.
Baton Rouge, LA
Matt Hutter, M.D.
President; Professor of Surgery; Director
American Society for Metabolic and Bariatric Surgery; Harvard Medical School; American Society for Metabolic and Bariatric Surgery
Several anti-obesity medications (AOMs) have been approved by the Food and Drug Administration (FDA) for weight loss and chronic weight management. The AOMs Qsymia, Saxenda, and Contrave reliably help people lose 8% to 14% of their total body weight. There’s no one best med; the goal with all AOMs is to achieve 4% to 5% weight loss after three months at the full prescribing dose. If that hasn’t happened, it may be time to try another AOM.
Yes, it is. When the American Medical Association officially recognized this in 2013, it was an important step forward in terms of educating millions of people, including health care providers, about the fact that obesity is not a personal choice or a character flaw.
Keto may work in the short term—by providing a limited framework for making food choices—but research has shown that long-term adherence is tricky.
Having a body mass index (BMI) of 30 or above, which is technically considered obese, comes with many weight-related health complications including cardiovascular issues, high blood pressure, sleep apnea, and type 2 diabetes.
What Is Obesity Again?
At its most basic level, obesity is an excess accumulation of fat that creates a risk to your health. It’s defined by a person’s Body Mass Index (BMI), which is calculated via the following mathematic equation (Warning: you’ll likely need to use an online conversion tool, as it utilizes European metrics):
Weight (in kilograms) / Height (in meters) squared = BMI
a BMI of 25.0 to 29.9 is considered overweight
a BMI of 30 or more is considered obese
Is Obesity a Disease?
You hit the nail on the head. Like type 1 diabetes or multiple sclerosis, obesity is a disease…and a difficult-to-control one at that. When the American Medical Association officially recognized this in 2013, it was an important step forward in terms of educating millions of people, including health care providers, about the fact that obesity is not a personal choice or a character flaw.
The Obesity Medicine Society adds that recognizing obesity as a disease also helps to shine a light on it as a stubborn, treatment-resistant condition with far-reaching health implications that deserves to be taken seriously. “For most people suffering with obesity,” they say, “simply eating less and moving more will not result in sustainable long-term weight loss.”
What Are the Best Treatments for Obesity?
With obesity causes as varied as genetics, environment, socioeconomic status, medications, food quality, and more, obesity is a complicated disease. It makes sense, then, that treatment options are complicated, too. But they do exist, and they’re far more varied than just the pat “eat less and move more” rhetoric.
Read on for some of the main categories of treatments currently available for obesity.
Lifestyle and Behavioral Modification
This category typically includes weight-loss efforts designed to help people consume fewer calories and increase physical activity. Examples include adopting a heart-healthy dietary pattern like the Mediterranean diet, joining a walking program…you get the idea.
Unfortunately, when it comes to obesity, those changes don’t tend to result in boatloads of weight-loss success. Experts say there is a gulf between perception and reality when it comes to the widespread belief that diet and exercise can reverse or simply reduce obesity. Our body is designed to maintain its highest weight (you can thank evolution for that one) so when we try to shed pounds by reducing caloric intake and increasing exercise, it will pull all sorts of tricks to get us back to that higher weight, like ramping up our appetite when we start working out more. Only about 5% of people will successfully treat their obesity using these approaches.
Now, that’s not to say exercise and nutrition aren’t important. In fact, they’re downright critical for overall health, cardiac health, mental health, and more. And once weight loss is achieved, exercise can help us to maintain that loss. But it takes a lot of exercise—between six and 10 hours—to lose one pound.
And trendy diets, like the Keto diet or intermittent fasting, can work in the short term, but long-term adherence is tricky. Let’s say you try the Keto diet, which features lots of protein and fat while severely limiting carbs. This can help you navigate an obesogenic environment by providing a limited framework for making food choices. But what happens when you’re at a friend’s birthday party and there aren’t any Keto options? You may have a piece of cake, which then makes it easier to rationalize other non-Keto options. Soon, you’re back to where you started.
Some strategic behavioral modifications do have science backing them up. These might not help you reverse obesity, but they can help you become more aware of why you eat the foods you eat, which in turn can possibly help you lose weight. Some examples include:
Mindful eating: A big part of how much we eat has to do with mindfulness. When we eat slowly, paying attention to the smell, texture, and taste of that silky fettucine or juicy, crisp cucumber salad, we don’t only get the chance to savor the food more, but deliberate acts like chewing carefully and putting the fork down between bites take time, which gives your stomach the chance to send an “I’m getting full” signal to the brain, so you don’t overeat.
Food journaling: Studies repeatedly show that keeping a food diary enhances weight-loss attempts. The act of recording your meals and snacks prompts self-reflection, which helps you make (or keep making) smart nutrition decisions. Actual journals work, but so does jotting it down on your phone.
Structured weight-loss programs: Popular programs like WW (formerly known as Weight Watchers), Nutrisystem, and Noom have all yielded positive results.
At the Academy of Nutrition and Dietetics, you can find a local Registered Dietitian Nutritionist certified in weight management to help you craft a plan.
Anti-Obesity Medications (Also Known as Weight-loss Pills)
Several anti-obesity medications (AOMs) have been approved by the Food and Drug Administration (FDA) for weight loss and chronic weight management. In order to qualify for a prescription, you need to have a BMI of 30 or greater. Alternatively, if you have a BMI of 27 or greater PLUS a weight-related health complication) such as high blood pressure, sleep apnea, or type 2 diabetes, you may be eligible as well, even though you’re not technically obese.
The AOMs Qsymia, Saxenda, and Contrave reliably help people lose 8% to 14% of their total body weight. This is key, as a loss in this range is known to bring about a bevy of health improvements, including a reduction in various heart-related risk factors; a reversal of sleep apnea; prevention of, or even remission of type 2 diabetes; and more.
Prescription AOMs work in several different ways. Some may make you feel less hungry; cause you to feel fuller, sooner; or may make food taste less appealing. Others can make it more difficult for the body to absorb fat or may ramp up your metabolism, causing you to burn more calories.
These medications aren’t used in a vacuum, though—they need to be paired with enhancements to your usual dietary and exercise routines. (The same goes for all the obesity treatment categories described here.) Your doctor will work with you to find several behavioral modifications that feel manageable and work with your lifestyle, and those will be combined with a specific medication.
Your doctor will also ask you to return for a check-up around one month (to monitor your heart rate, blood pressure, and other vitals), and again at three months. In general, the goal with AOMs is to achieve 4% to 5% weight loss after three months at the full prescribing dose. If that hasn’t happened, it may be time to try another AOM.
Many people wonder whether they’ll need to be on an AOM forever. Obesity is much like many other diseases in that medication can help, but just because your condition improves does not mean you no longer need medicine. AOMs help change your brain chemistry so you can make healthy choices. Once you stop taking it, your old brain chemistry will resume and the obesity may follow suit. Your doctor will help you chart out a long-term plan. A minority of patients will stop, but most stay on.
Below you’ll find some of the most frequently prescribed drugs being used to treat obesity.
Qsymia (phentermine + topiramate ER): Phentermine is a powerful stimulant that works by decreasing hunger and cravings. It can be prescribed alone, but many doctors prefer to use it in combination with topiramate, a migraine medication that helps to balance out some of the stimulating properties of phentermine, which otherwise might cause a rapid heart rate, high blood pressure, or insomnia. Interestingly, topiramate also makes most carbonated beverages taste metallic, so if a patient struggles with reducing soda intake, it can make for a nice fit.
Saxenda (liraglutide): Historically used to treat diabetes, liraglutide is now a go-to choice for many patients with obesity. That’s because the daily injectable drug, part of a class of medications called GLP-1 agonists, works in the appetite center of the brain, stepping on the gas pedal in terms of satiety and fullness and pushing on the hunger brake. There’s also a new generation of GLP-1 agonists on the horizon, including semaglutide, which is taken orally instead of being injected.
Contrave (naltrexone + bupropion): Naltrexone and bupropion have both been used independently for years—bupropion is an antidepressant that also helps people quit smoking, and naltrexone helps those fighting alcohol and opioid dependence. Bupropion treats obesity by affecting the appetite center in the brain. Naltrexone is thought to help people resist food cravings and may also intensify bupropion’s appetite-dampening effects
The term “endoscopic” means a doctor uses a tiny, flexible instrument to enter your gut through your mouth. Once inside, one of a number of approaches may be used to help reduce food intake. These include an intragastric balloon, which is exactly what it sounds like: a balloon is inflated in the stomach, where it takes up space to lower your appetite and encourage the patient to consume smaller portions.
In endoscopic suturing, tiny stitches are sewn into the inside of the stomach, making a person feel fuller on less food.
Endoscopic procedures are done on a same-day, outpatient basis, and are less invasive than surgery (meaning fewer risks). About 10% to 20% of people will reach their weight-loss goal using endoscopic methods. Balloons, like the Obalon, need to be removed after six months. Pregnant women should avoid these procedures.
Metabolic Surgery (a.k.a. Bariatric Surgery)
This is the treatment category with the most risk but also the most reward. Surgery is usually reserved for people with a BMI greater than 40, or a BMI over 35 along with an obesity-related health condition. It has the potential to not just drastically reduce weight, but to also help manage, improve or even reverse more than 40 obesity-related conditions, including heart disease, sleep apnea, high cholesterol, certain cancers, and more.
In some trials, 70% of patients who undergo surgery show remission of type 2 diabetes within a few days.
A few types of metabolic surgery exist. They involve altering the anatomy of the stomach, intestines, or both, to change how food is digested. This results in decreasing the intake and absorption of calories. Metabolic surgery can also favorably alter the production of hormones that regulate fat storage.
Two of the more common bariatric procedures used to treat severe obesity are the laparoscopic sleeve gastrectomy (a.k.a. the gastric sleeve) and the laparoscopic gastric bypass. Both are done using surprisingly small incisions and the patient usually goes home the next day.
Sleeve gastrectomy: About 80% of the stomach is removed, leaving you with a thin, banana-shaped stomach. This limits the quantity of food that can be comfortably consumed at any given time. It also exerts a strong effect on appetite-regulating hormones, so people generally just don’t feel as hungry as they did pre-surgery. People lose about 55% of their extra weight in the 12 to 18 months following sleeve gastrectomy.
Gastric bypass: A surgeon essentially creates a new, much smaller stomach (about the size of an egg), then connects it directly to the small intestine. The first step reduces the amount of food that can be comfortably consumed, and the second step prevents the body from absorbing as many calories as it otherwise would. People lose about 73% of their extra weight in the 12 to 18 months following gastric bypass.
Insurance companies typically do cover metabolic surgery, so long as you meet the proper criteria.
Look for a compassionate, empathetic bariatric surgeon. Ask your primary care physician for recommendations; ask friends who also have obesity and have explored surgery as an option; or visit the American Society for Metabolic & Bariatric Surgery or the Obesity Medicine Society, both of which have tools to help you search for experienced local providers.
People who have lived with the medical and psychological symptoms of obesity for years are typically overjoyed to be rid of them (good-bye, sleep apnea). Reducing their weight enough to exit the obesity category typically corresponds with immensely positive changes like being able to play on the playground with one’s kids, not feeling nervous about whether the seat on the plane will be large enough, and enjoying clothing shopping.
When you have obesity, losing weight can feel like a Herculean endeavor. Many factors conspire against you. But you are not powerless. We repeat: you are not powerless. Many options exist, so it’s crucial that you educate yourself and ask your health care provider lots of questions. Once you’re able to find a method, or even a combination of methods, that work for you, you have the ability to improve many obesity-related symptoms, and possibly reverse them.
- BMI Calculation: Pennington Nutrition Series. (2009). “Weight Loss Methods.” pbrc.edu/training-and-education/pdf/PNS_weight_loss_methods.pdf
- Bariatric Surgery: UCLA Health. (n.d.). “Gastric Sleeve.” surgery.ucla.edu/bariatrics-gastric-sleeve
- Diabetes and Bariatric Surgery: International Journal of Environmental Research and Public Health. (2019). “Remission of Type 2 Diabetes Mellitus after Bariatric Surgery: Fact of Fiction?” ncbi.nlm.nih.gov/pmc/articles/PMC6747427/
- Endoscopic Procedures: University of Michigan Health Lab. (2019). “New Endoscopic Procedures Offer Alternative to Bariatric Surgery.” labblog.uofmhealth.org/body-work/new-endoscopic-procedures-offer-alternative-to-bariatric-surgery
- Prescriptions for Obesity: National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). “Prescription Medications to Treat Overweight and Obesity.” niddk.nih.gov/health-information/weight-management/prescription-medications-treat-overweight-obesity
- Type 2 Diabetes and Weight Loss: Diabetic Medicine. (2019). “Behaviour change, Weight Loss and Remission of Type 2 Diabetes: A Community-Based Prospective Cohort Study.” ncbi.nlm.nih.gov/pubmed/31479535
- Food Diary Research: Kaiser Permanente. (2008). “Keeping a Food Diary Doubles Diet Weight Loss, Study Suggests.” sciencedaily.com/releases/2008/07/080708080738.htm
- Obesity Overview: Obesity Medicine Association. (n.d.). “What is Obesity?” obesitymedicine.org/what-is-obesity/