Obesity, affecting nearly 40% of adults worldwide, poses significant health risks, including cardiovascular diseases, type 2 diabetes, dyslipidemia, and increased mortality. While treating obesity is challenging, with calorie restriction often leading to rebound weight gain, various strategies, from lifestyle changes to medical interventions, offer hope for achieving and maintaining a healthy weight. This article explores these strategies, drawing upon scientific research and real-life success stories to provide a comprehensive guide to weight loss.
The Multifaceted Nature of Obesity
Obesity, as defined by The Obesity Society (TOS), is a multi-factorial chronic disease resulting from excess fat accumulation that presents a risk to health. Multiple organ systems are affected, leading to additional chronic diseases associated with obesity. It may present itself with multiple clinical phenotypes and also varied treatment responses, likely originating from our limited understanding of the mechanisms of weight regulation.
Obesity is traditionally defined as an excess of body fat and is classically categorized in clinical practice in terms of body mass index (BMI). A BMI (in kg/m2) in the range of 18.5-24.9 is considered normal, 25-29.9 is overweight, and ≥30 is considered obese. Severe obesity, which is defined as a BMI over 40 kg/m2, is an alarming public health issue. It should be noted, however, that BMI, although easy to gauge, has limitations when utilized as a diagnostic tool because it does not account for the exact muscle mass or fat mass, especially visceral adipose tissue. Visceral adipose tissue is more metabolically active and associated with the pathophysiology seen in obesity such as insulin resistance. Waist circumference is an alternative to BMI and can be used as a complement to BMI. Kim et al. found a linear association between waist circumference and all-cause mortality in a study on 23,263,878 subjects over the age of 20 years. Another reason fixation on BMI is not entirely accurate is because it does not account for factors such as age, sex, and ethnic variation. BMI also does not correlate with the risk of death at a population level.
Obesity-driven inflammatory processes are responsible for a large portion of the damage inflicted by excess weight. Obesity has harmful effects on various body systems, most notably on the cardiovascular and endocrine systems, but also on the kidneys, liver, lungs, joints, and immune system. The cardiometabolic consequences of obesity such as insulin resistance, glucose intolerance, type 2 diabetes, arterial hypertension, atherosclerosis, and dyslipidemia are all stressors on the heart and vascular system. The lipid profile in obesity is marked by an increase in triglycerides and free fatty acids. Obesity leads to oxidative stress from proinflammatory cytokines and adipokines.
Obesity is also strongly associated with metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis, which is inflammation-driven. Obesity also elevates the risk of developing some types of cancer including colorectal, esophageal, liver, and kidney malignancies. Both cardiovascular disease and cancer contribute to excess mortality associated with obesity. Obesity is the strongest risk factor for obstructive sleep apnea. In this condition, excessive adiposity may restrict the lungs and impede their inflation, and adipose tissue in the diaphragm may compromise muscle strength, leading to intermittent hypoxia and hypercapnia. Other health issues associated with obesity include depression, anxiety, and chronic kidney disease.
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Dietary Strategies for Weight Loss
Treating obesity has evolved in recent years, with various shifts in dietary, pharmacological, and surgical strategies available for the management of obesity. There are various dietary styles with goals of controlling macronutrient composition and calorie restriction. Dietary advice historically has seen energy restriction as the foundation for weight loss. Numerous studies have demonstrated that dietary macronutrient composition is not the most significant contributing factor for weight loss. However, guidelines have started to include a more nuanced understanding that there is a synergy between dietary nutrients and their food sources.
When looking at macronutrient content, initially, dietary fat, carbohydrate, and protein content are scrutinized. The low-or very-low fat intake approach is recommended for inducing significant short-term weight loss, but its long-term efficacy is not superior to dietary interventions with higher fat content. The low carbohydrate diet involves consuming a low content of carbohydrates and a high content of fat and protein. It is especially suitable for individuals with type 2 diabetes and/or insulin resistance. Exceeding 6-12 months of use may have undesired effects by increasing LDL cholesterol and cardiovascular risk in some studies, but others have found no difference. In a randomized study of overweight adults, following a low-fat or high-fat diet with average or high protein resulted in an average 7% weight loss at 6 months, irrespective of diet type.
At this time, the evolution of dietary guidelines from isolated macronutrients to broader dietary patterns is receiving major attention. One such example is the Mediterranean diet, which is rich in plant-based food with high dietary fiber and antioxidants. The Mediterranean diet has a higher composition of fatty acids, unlike the conventional Western diet. In addition to its effect on body weight, a variety of health benefits have been ascribed to it. These include favorable effects on heart and brain health and decreased diabetes risk. Much of the recommended annual weight loss diets often seen in US News and World Report reflect a variety of these dietary patterns, highlighting that diets are more than their nutrient content. Finally, the microbiome has a variety of mechanisms through which it affects obesity, and pre/probiotic therapies could be a helpful addition to a weight loss regimen.
The Role of Exercise
Regular physical activity is also recommended as a component of weight loss programs not only for energy expenditure but for cardiometabolic health as well.
Pharmacological Interventions
Perhaps the least successful of the FDA-approved weight loss drugs in terms of achieving weight loss maintenance is Orlistat (tetrahydrolipstatin). An older drug, orlistat inhibits pancreatic lipases which break down dietary fat. By reducing absorption of fat via the intestine, it promotes weight loss. Patients are advised to consume a low-fat diet to combat the side effects of oily stool. This drug leads to a weight loss nadir at around 36 weeks with a weight regain that happens at around 52 weeks. However, the weight regain is relatively mild and by 104 weeks there is still overall weight loss.
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Anti-obesity medications such as Contrave (bupropion/naltrexone) or Qsymia (phentermine/topiramate) also appear to be effective for maintaining weight loss. Admittedly, the lesser potency of these drugs in the initial weight loss phase often overshadows their potential for usage for weight loss maintenance purposes. For instance, the Contrave Obesity Research studies (COR-I, COR II, COR-BMOD, and COR diabetes) were performed over a 56-week period. Contrave appears to modulate appetite and reward centers. For Contrave, a weight loss plateau seems to occur for all the COR studies around 32 to 36 weeks with overall weight loss around 8 to 9%. Qsymia has the longest-term data of the available oral anti-obesity drugs, upwards of 108 weeks. This drug also appears to induce satiety and reduce hunger. Qsymia has demonstrated overall efficacy for weight loss maintenance, achieving sustained weight loss of 9-10% at the 108-week mark compared to 1.8% for placebo.
Surgical Options
The intragastric balloon is an anti-obesity intervention in which a silicone balloon is endoscopically deployed and filled with saline and inflated for 6 months. It is a temporary and minimally invasive therapy that reduces stomach capacity and results in decreased hunger and food intake.
Bariatric surgery is indicated in patients with a BMI above 40 independent of coexisting comorbidities or in patients with a BMI over 35 with a history of comorbidities such as type 2 diabetes or hypertension. There are two common procedures currently used: sleeve gastrectomy and gastric bypass. Emerging evidence suggests that the sleeve procedure is associated with few reoperations, but significant regain of weight while the bypass procedure can lead to more durable weight loss and glycemic control. There is strong evidence to support that bariatric surgery results in greater long-term weight loss than even the top nonsurgical interventions and a recent retrospective study showed superior cardiovascular benefit for sleeve gastrectomy and gastric bypass compared to GLP-1 treatment over a 10-year follow-up period. Variations of Roux-en-Y gastric bypass limb lengths have shown potentially increased weight loss and metabolic benefit, but also, possible early and late significant complications. The metabolic efficacy of bariatric surgery in increasing gut production of GLP-1 to supraphysiologic levels postprandially is considered a major factor in early weight loss.
The Power of GLP-1 Receptor Agonists
The discovery of the gut hormone glucagon-like peptide-1 (GLP-1) and the synthesis of agonists for its corresponding receptor (GLP-1 receptor) has tremendously impacted treatment for weight reduction. GLP-1 medications have revolutionized weight loss and can reduce body weight in obese patients by between 15% and 25% on average after about 1 year. Their mode of action is to mimic the endogenous GLP-1, an intestinal hormone that regulates glucose metabolism and satiety.
However, significant questions remain about these drugs. Based upon the “set point” theory of weight regulation, the possibility of needing these medications over extended periods of time to avoid the inevitable weight regain may cause the clinician to consider other treatments. The lack of long-term clinical trials in weight management compels clinicians to consider potentially unforeseen long-term side effects of the GLP-1 receptor agonists. The known risks of pancreatitis, gastroparesis, and lean body mass loss are variables to be considered as well.
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Mark Johnson's Weight Loss Success Story
One inspiring example of successful weight loss comes from Mark Johnson, a 48-year-old Designated Supervisor of Locomotive Engineers from Davenport, Iowa. Weighing 286 pounds, Mark struggled with breathing and relied on fast food and heavy restaurant meals. His manager at the Canadian Pacific Railway recommended he seek guidance to learn healthy habits.
Mark's journey began with a training coach who emphasized the importance of dedication and a 100% commitment to the plan. Nutrition became the cornerstone of his transformation. Mark learned to read food labels, keeping his fats, sodium, and added sugars down. He switched to eating a serving of lean protein and a complex carbohydrate roughly every four hours, ensuring each serving had minimal fat, sodium, and added sugar. Meal-prepping became an essential part of his routine, preventing him from resorting to unhealthy takeout options.
Alongside his dietary changes, Mark incorporated running into his routine. Starting with walking on the treadmill, he gradually increased his speed and distance. Seeing the scale go down each Monday at his weekly weigh-in was a powerful motivator. Running and improved nutrition went hand-in-hand, fueling each other.
In less than a year, Mark lost 119 pounds, dropping from 286 pounds to 167 pounds. He went from struggling to walk to running 8- to 11-minute miles and from a size 48/50 pants to a 32.
Mark's advice for others embarking on a similar journey includes:
- Find an accountability partner: Someone to check in with you and keep you honest.
- Incorporate both nutrition and exercise: Find a nutrition plan that works for you and aim for at least 60 minutes of exercise daily.
- Make the change for yourself: True change comes from within.
News 5 and Ethical Standards
News 5 wants to share with our viewers a change to our on-air staffing. Meteorologist Mark Johnson is no longer employed at WEWS.“We want our audiences to know that News 5 and its parent company, Scripps, take protecting our audiences’ trust very seriously by requiring our employees to adhere to the highest ethical standards. We cannot provide further details, as this is a personnel matter,” said Steve Weinstein, WEWS VP and GM.Our commitment to being the weather team Northeast Ohio turns to for safety and accuracy remains steadfast.