Weight loss, in the context of medicine, health, or physical fitness, refers to a reduction of the total body mass. This reduction can stem from a loss of fluid, body fat (adipose tissue), or lean mass (namely bone mineral deposits, muscle, tendon, and other connective tissue). Weight loss can occur unintentionally due to malnourishment or an underlying disease, or from a conscious effort to improve an actual or perceived overweight or obese state.
Intentional weight loss is defined as the reduction of total body mass achieved through deliberate efforts to improve fitness and health, or to alter one's appearance by slimming down. It is achieved by adopting a lifestyle in which fewer calories are consumed than are expended.
The Benefits of Intentional Weight Loss
For individuals who are overweight or obese, intentional weight loss can yield several health benefits:
Reduced Health Risks: Obesity is a risk factor for conditions like diabetes, cancer, cardiovascular disease, high blood pressure, and non-alcoholic fatty liver disease. Reducing obesity lowers these risks.
Increased Fitness: Weight loss can lead to improved physical fitness.
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Delayed Onset of Diabetes: Intentional weight loss may delay the onset of diabetes.
Reduced Pain and Increased Movement: Weight loss can reduce pain and increase movement in people with osteoarthritis of the knee.
Reduction in Hypertension: Weight loss can lead to a reduction in hypertension (high blood pressure).
The Complex Relationship Between Weight Loss and Mental Health
Obesity is related to an increased risk of several health complications, including depression. Many studies have reported improvements in mood with weight loss, but results have been equivocal. Intentional weight loss is often accompanied by improvements in mood.
Meta-Analysis of Weight Loss Interventions and Depression
A meta-analysis examined changes in symptoms of depression that were reported in trials of weight loss interventions. The meta-analysis sought to examine whether different types of weight loss interventions (including lifestyle modification, non-dieting, dietary counseling, exercise-alone, and pharmacotherapy) are associated with differential changes in symptoms of depression among obese individuals. It also assessed, through meta-regression, the relationship between weight loss and changes in symptoms of depression.
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Methodology
The Ovid MEDLINE database was searched for studies published between 1950 and January 2009. The search strategy was to intersect several terms related to obesity and weight change (obese, obesity, body mass index, adipose, adiposity, overweight, weight loss, weight gain, weight change, weight reduction, weight increase) with terms related to depression (mood, depressed, depression, depressive, suicide, suicidal). Results were filtered to return only studies of human subjects, published in English.
The MEDLINE search returned 8799 publications, of which 5971 were published in English and included human subjects. Only randomized controlled trials (n = 394) were considered for inclusion. In addition, weight and symptoms of depression must have been assessed at baseline and post-treatment. Trials were excluded if they: included only persons with binge eating disorder; included children or adolescents; reported weight change with antidepressant or other psychotropic therapies; or manipulated individual macro- or micronutrients without weight loss as an intended outcome.
Each included article was reviewed by two authors to extract the duration of treatment, the method of assessing symptoms of depression, and a description of each study intervention.
An intervention was coded as lifestyle modification if its description included: mention of counseling related to diet and exercise; mention of diet and exercise prescriptions plus behavioral interventions; or use of a known lifestyle modification intervention (e.g., the LEARN manual). Non-dieting interventions were defined as those that were described as such, or that focused on health and self-acceptance rather than weight loss. Interventions that included counseling and instruction to achieve a reduction in calorie intake, without increasing energy expenditure, were coded as dietary counseling. Interventions that manipulated energy level and content of participants’ diets, but included no counseling, were coded as diet-alone interventions. Exercise-alone programs were defined as interventions in which increased physical activity was prescribed or supervised in the absence of instructions to reduce calorie intake. Pharmacologic interventions were those that included administration of orlistat, sibutramine, or rimonabant without an accompanying lifestyle modification program. Nearly all pharmacotherapy studies included a placebo group. Control groups included persons who were placed on a waiting list for one of the above active treatments, or who received only standard advice/printed materials, an attention-control intervention, or no treatment.
For each study group, the same two authors also extracted sample size and participants’ mean (± standard deviation or standard error) weights and depression scores at baseline and at post-treatment. BMI was extracted when weight was not reported. Data from intent-to-treat samples and analyses were used when available. When only change values were reported for weight or symptoms of depression, or when results were collapsed across multiple groups, the corresponding authors were contacted to request mean values (and a measure of variability) for each study group. Inability to ascertain the necessary data led to exclusion of eight studies. For the final 31 included studies (total n = 7937), the correlations between pre- and post-treatment values for weight and symptoms of depression were requested.
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Two additional variables - presence/absence of supervised exercise sessions and intensity of counseling - were extracted for each treatment group. Interventions that included at least 16 counseling visits in the first 6 months (as in the Diabetes Prevention Program) or before treatment ended (whichever occurred first) were coded as high-intensity-counseling. Those with fewer than 16 sessions in 6 months were coded as moderate-intensity-counseling.
Results
The variety of interventions precluded a single meta-analysis. Thus, separate between-groups effects were computed for each of the following comparisons, which commonly occurred in the included studies:
- Lifestyle modification vs. control
- Lifestyle modification vs. non-dieting
- Lifestyle modification vs. dietary counseling
- Lifestyle modification vs. exercise-alone
- Exercise-alone vs. control
- Pharmacologic agent vs. placebo
A random effects model was computed for each of the six between-groups comparisons described above. For each analysis, the standardized mean difference (SMD) was reported accompanied by its 95% confidence intervals (CI) and associated Z and p values. The statistical significance and magnitude of heterogeneity of effects were assessed using the Q test and I2 statistic, respectively. Funnel plots were reviewed and a fail-safe N (the number of studies with null findings that would need to be included in the analysis to render a significant effect non-significant) was computed for each analysis to examine the possibility of publication bias.
For the within-groups comparisons (of baseline vs. post-treatment symptoms of depression), a random effects model was computed for each active treatment type. When possible, meta-regressions also were conducted to determine the relationships of group-level covariates (e.g., mean weight change, treatment duration, counseling intensity, and the presence of supervised exercise sessions) to the effect size for changes in depressive symptoms.
Of the 31 included studies, 7 and 9 reported results from intent-to-treat and completers’ analyses, respectively. Handling of missing data was not specified in the remaining 15 studies. Correlations between pre- and post-treatment values for weight and for depressive symptoms were unattainable for 65.8% of comparisons.
The 31 included studies contributed a total of 34 comparisons to the six between-groups analyses. There were seven comparisons of lifestyle modification vs. control (total n = 1216), six of lifestyle modification vs. non-dieting (n = 364), three of lifestyle modification vs. dietary counseling (n = 95), four of lifestyle modification vs. exercise-alone (n = 281), and five of exercise-alone vs. control (n = 320). The nine comparisons of pharmacotherapy vs.
Lifestyle modification programs were found to induce significantly greater reductions in symptoms of depression than control and non-dieting interventions. Reductions in symptoms of depression were marginally greater with lifestyle modification than with dietary counseling and exercise-alone. The largest effect size was found for the comparison of exercise-alone with control.
The Role of Lifestyle Modification
The meta-analysis indicated that lifestyle modification was superior to control and non-dieting interventions for reducing symptoms of depression, and marginally better than dietary counseling and exercise-alone programs. Standard group-based LM with weekly sessions. Same LM as above. Set in community center. LM vs. LM vs. LM vs. Same number and schedule of visits as above, but sessions focused on body acceptance, eating behavior, activity, nutrition, and social support. LM vs. Standard group-based LM with 24 weekly sessions lasting 90-120 minutes each. Navy ship. LM vs. LM vs.
Exercise as an Intervention
Exercise-alone programs were superior to controls. Home-based, graduated, low-level exercise protocol consisting of light aerobic exercise and resistive training. EX vs. EX vs. Weekly group exercise sessions, instructions to exercise two additional times per week, dietary counseling every 2 weeks, and 3-day food records monthly. Four supervised sessions per week of mild stretching and range-of-motion exercises (vs. LM vs. LM vs. EX,EX vs. Four supervised sessions per week of mild stretching and range-of-motion exercises (vs. LM vs. CEX vs. EX vs. EX vs. EX vs. Identical exercise goal. LM vs. EX,EX vs. LM vs. C,EX vs.
Pharmacological Interventions
No differences were found for comparisons of pharmacologic agents and placebos. 5-15 mg/day of sibutramine and pamphlet on healthy eating and physical activity. RX vs. RX vs. Prescribed LCD, providing 24% of calories from protein, 46% from carbohydrate, and 30% from fat. LM vs. LM vs. RX vs. RX vs. RX vs. LCD: Prescribed energy deficit of 600 kcal/day. RX vs. RX vs. RX vs. LM vs. RX vs. RX vs. RX vs.
Within-Group Analyses
Within-group analyses found significant reductions in symptoms of depression for nearly all active interventions. On average, obese individuals in weight loss trials experienced reductions in symptoms of depression.
The Downside of Intentional Weight Loss: A Focus on Dieting
While intentional weight loss can be beneficial, it's crucial to acknowledge the potential downsides, particularly those associated with dieting.
The Ineffectiveness of Dieting
Intentional weight loss attempts almost never lead to long-term significant weight loss or improvement in health, and often have negative side effects. "Dieting" is defined here as any attempt to manipulate body size through food and/or movement - this would include short-term diets, “fad” diets, diets that eliminate foods, and diets that are referred to as “lifestyle changes.” If the goal is to create weight loss through food and/or movement, it counts! While most people are able to lose weight short term, almost everyone gains it back, with up to two-thirds of people gaining back more than they lost.
The Dangers of Weight Cycling
Repeated dieting typically means repeated cycles of weight loss and regain. This is "weight cycling" (sometimes referred to as "yo-yo dieting") and it comes with its own negative side effects. In fact, the research shows that it is possible that the association between weight and health risk can be better attributed to weight cycling than body size. Weight cycling is associated with a shorter lifespan, and has been shown to increase the risk of diabetes, high blood pressure, high cholesterol, and heart disease.
The Harm of Weight Stigma
Internalized negative attitudes about weight, known as weight stigma, is another mediator between body size and health. Studies show that weight stigma increases the risk of high blood pressure, metabolic syndrome, diabetes, high cholesterol, and eating disorders. This means that placing the focus of medical care on weight management is harmful and has the opposite of its intended effect on health.
Dieting and Eating Disorders
Dieting is one of the most important predictors of development of eating disorders. In fact, prescribing diets often equates to prescribing disordered eating behaviors. Dieting can lead to severe restrictive eating and malnutrition, cycles of starvation and binge eating, as well as other eating disorder behaviors and their medical complications.
Risks Associated with Weight Loss Pills and Surgeries
Weight loss medications may lead to short-term weight loss, but cause weight cycling in the long run, along with other potential side effects. Weight loss surgeries carry a significant risk of many complications, including death.
Unintentional Weight Loss: A Cause for Concern
Unintentional weight loss, on the other hand, is a decrease in body weight that occurs without conscious effort. It is defined as a loss of 10 pounds (4.5 kilograms) or 5% of your normal body weight over 6 to 12 months or less without knowing the reason. Unintentional weight loss in people older than 65 years is associated with increased morbidity and mortality.
Common Causes of Unintentional Weight Loss
- Non-Malignant Diseases: These are more common causes of unintentional weight loss than malignant causes.
- Malignancy: However, malignancy accounts for up to one-third of cases of unintentional weight loss. Cancer, a very common and sometimes fatal cause of unexplained (idiopathic) weight loss. About one-third of unintentional weight loss cases are secondary to malignancy. Patients 18 years and older presenting with weight loss are up to 12.5 times more likely than those without weight loss to have cancer. For people older than 60 years, more than one in 10 presenting with weight loss will be diagnosed with cancer.
- Medication Use and Polypharmacy: These can interfere with the sense of taste or induce nausea and should not be overlooked as causative factors.
- Social Factors: Isolation and financial constraints may contribute to unintentional weight loss.
- Loss of appetite: A loss of appetite may be due to:Feeling depressed, Cancer, even when other symptoms are not present, Chronic infection such as AIDS or tuberculosis, Chronic illness, such as COPD or Parkinson disease, Drug use such as amphetamines and cocaine, Medicines, including chemotherapy medicines, and thyroid medicines, Stress or anxiety
- Chronic digestive system problems: that decrease the amount of calories and nutrients your body absorbs, including:Celiac disease, Diarrhea and other infections that last a long time, such as parasites, Chronic inflammation of the pancreas, Removal of part of the small intestine, Overuse of laxatives
- Other causes: such as:Eating disorders, such as anorexia nervosa that have not been diagnosed yet, Diabetes that has not been diagnosed, Overactive thyroid gland
Evaluation of Unintentional Weight Loss
A baseline evaluation for unintentional weight loss includes a complete history and physical examination focusing on symptoms that could indicate the cause of weight loss. An article on the comprehensive in-office geriatric assessment published in American Family Physician reviewed tools to assess cognitive impairment, depression, and functional status, all of which can lead to weight loss. Medication and supplement use should be reviewed. Physical examinations should assess any concerning findings from the history and include assessment of the oral cavity and dentition and examination for heart, lung, gastrointestinal, or neurologic abnormalities. Shared decision-making and goals of care should guide diagnostic evaluation.
Initial workup for most patients should include laboratory studies and imaging. Laboratory tests include complete blood count, basic metabolic panel, liver function tests, thyroid function tests, C-reactive protein level, erythrocyte sedimentation rate, glucose measurement, lactate dehydrogenase measurement, protein electrophoresis, ferritin, urinalysis, and fecal occult blood testing. Low albumin and elevated total white blood cell count, platelets, calcium, or inflammatory markers are most associated with cancer.
Appropriate follow-up of patients with unexplained, unintentional weight loss is needed if the initial evaluation is unclear. Studies suggested that if the initial evaluation was normal and screening tests were negative, no further workup is needed, and a three- to six-month observation period is warranted. The length and frequency of follow-up should be specific to the clinician and patient.
Tests for Unexplained Weight Loss
A healthcare provider may order specific medical tests based on your symptoms, family history and other factors. For example, if you have symptoms of a peptic ulcer, your provider may recommend an upper endoscopy.
Other tests may include:
- Blood tests: Your blood can show signs of certain health conditions like diabetes, celiac disease and infections. It can also give your provider information about how your metabolism, thyroid and adrenal glands are working.
- Cancer screening tests: If your provider wants to rule out cancer, you may need screening or imaging tests. For example, a colonoscopy can detect colorectal cancer.
- Imaging tests: Tests like an MRI (magnetic resonance imaging) or CT scan (computed tomography scan) can provide detailed images of your organs, like your brain, heart, lungs and abdominal organs. You may need one of these tests if your provider wants to rule out tumors or diseases that may be visible on these scans.
- Urine test: A urinalysis can provide information about your kidneys and bladder, including certain health conditions and infections.
Treatment for Unintentional Weight Loss
Treatment should focus on the underlying cause and often involves a multidisciplinary team, including dentists; dietitians; speech, occupational, or physical therapists; and social service workers. Decreased saliva production, ill-fitting dentures, periodontal disease, and weakened mastication muscles can lead to poor dentition and impaired chewing. According to the Choosing Wisely campaign by the American Geriatrics Society, appetite stimulants and high-calorie supplements should be avoided secondary to lack of evidence on long-term survival and quality of life. Treatment should instead focus on feeding assistance, addressing contributing medications, providing appealing foods, and social support as indicated. Supplementation, if given, should provide extra calories but not replace scheduled meals and snacks.
Treatment should focus on the underlying cause if known. Dietary modifications that consider patient preferences and chewing or swallowing disabilities should be considered.
When to Contact a Healthcare Provider
Contact your provider if:
- You or a family member loses more weight than is considered healthy for their age and height.
- You have lost more than 10 pounds (4.5 kilograms) or 5% of your normal body weight over 6 to 12 months or less, and you do not know the reason.
- You have other symptoms in addition to the weight loss.
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