Weight Management Isn’t Just a Matter of Willpower, and We Need to Talk About All the Treatment Tools Available

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By the time she was 29 years old, Quinn, now 32, had grown accustomed to life on the weight-loss roller coaster. She says she's been overweight since childhood, and points to two reasons her repeated weight-loss efforts never lasted—namely, genetics and a thyroid condition that developed in her twenties. She'd clean up her diet, lose a few dozen pounds, and then gain them all back whenever she inevitably paused her regimen to catch her breath.

At 5'3" and nearly 300 pounds, her primary-care doctor eventually presented her with a more permanent solution: bariatric surgery. Although Quinn didn't have any obesity-related health issues at that point and felt comfortable with her size, she knew that wouldn't always be the case. "What scared me was getting to the point of becoming a mother," she says. "I'm still not a mom, but it was in my five-year plan, and I was worried about being the overweight, sideline mom who couldn’t keep up with my kids or run around the playground. I loved my body, but I wanted it to be the healthiest it could be."

So in April 2016, she underwent a sleeve gastrectomy, a surgery that reduced the size of her stomach by around 80 percent and helped her lose more than 100 pounds. "The sleeve works by restriction—you can only eat about a half-cup of food before you feel that sense of fullness—and hormonal changes," says says Shauna Levy, MD, MS, a surgeon and assistant professor at Tulane University Medical Center. "When we remove part of the stomach, it significantly decreases the hunger hormones, particularly ghrelin. That's almost more important than the restrictive aspect of it."

Although medical intervention for weight loss is becoming more common—the rates of bariatric surgery have been steadily increasing since 2011—it's happening at a time when the conversation around obesity is more complex than ever. While fashion and wellness worlds are finally embracing a body-positivity movement that celebrates all shapes and sizes, diminishing the long-held stigma society has harbored against overweight people, the science doesn't lie: Carrying too much excess weight can be detrimental to a person's long-term health. And in some cases—many cases, in fact—diet and exercise alone aren't fully effective when it comes to losing large amounts of weight and maintaining that loss.

"At the end of the day, obesity is a medical issue," says Dr. Levy. The World Health Organization estimates that 13 percent of adults were considered obese in 2016, meaning they had a BMI of 30 or more. According to the National Institutes of Health, being overweight (a BMI of 25 or above) or obese puts people at greater risk for heart disease, type 2 diabetes, sleep apnea, stroke, dementia, and certain types of cancer, including those affecting the breasts, colon, gallbladder, and uterus. Overweight or obese mothers are also more likely to experience pregnancy complications, such as gestational diabetes, preeclampsia (high-blood pressure during pregnancy), premature birth, stillbirth, and neural tube defects.

While Dr. Levy says most people won't start seeing obesity-related complications until their BMI reaches 30 or above, these issues do sometimes present at lower weights. For example, she says, those of Asian descent frequently experience health problems linked to weight at BMIs of around 27. While doctors often suggest weight loss as a first step for preventing and treating these issues, in practice, it's often easier said than done.

obesity treatment strategies
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Why diet and exercise don't always lead to major weight loss

Conventional wisdom says that preventing obesity is as simple as eating in moderation and exercising regularly, but it's a lot more complicated. For one thing, many are hardwired, evolutionarily, to hang on to excess weight. "Our genetics haven’t changed in the past 200 years, but how we live, access to food, and types of food, physical activity, and types of jobs [have changed]," says Vijaya Surampudi, MD, assistant professor of medicine in UCLA's Division of Human Nutrition who works in the university's Center of Obesity and Metabolic Health. "We are all descendants of people who survived periods of hunger; our bodies, genetically, are very good at storing calories for use later. However, we live in a society of nutrient excess [and] many of us no longer enter periods of hunger." Much of this is thought to be due to our modern food system, filled with low-quality processed foods high in sugar, salt, and unhealthy fats.

Regardless, there are additional physical and psychiatric reasons some are more prone to obesity than others—and all of them must be addressed and treated for lasting weight loss to occur. "Some physical causes include endocrine disorders, genetic disorders, medication side effects, neurological injuries, or tumors that affect the part of the brain that controls hunger and satiety," says Nicole Garber, MD, chief of psychiatry at eating-disorder treatment center The Meadows Ranch. "From a psychological perspective, some people suffer from binge-eating disorder. Some people have night-eating syndrome, which is consuming at least 25 percent of one’s daily calories after the evening meal. There are some people who emotionally eat when they feel sad, bored, or anxious. Some survivors of trauma eat in order to feel like their body is less attractive and less at risk for a future assault," she adds.

"We know that the body is designed to defend against weight loss, even in someone who has excessive body weight." —Nicole Garber, MD

Doctors agree that in the absence of an underlying mental or physical health condition causing obesity, diet and exercise—in combination with lifestyle modifications like stress- and sleep-management programs and therapy—should always be the first strategies for treatment. But these things don't always work, because the truth is weight loss isn't just a matter of willpower. "We know that the body is designed to defend against weight loss, even in someone who has excessive body weight," says Dr. Garber. "Studies have shown that people can typically lose weight for about 6 to 9 months, and then changes occur in the body that decrease calorie expenditure and increase appetite. We've [recently discovered] that these changes are mediated through neurohormonal changes in the body, but the medical community is having to catch up with the new science and approach weight loss with the knowledge that the body is going to try and maintain its weight."

That was the case for Quinn, as well as for 28-year-old Rheannon, who took medication and eventually had a sleeve gastrectomy to help with weight loss. "Before the surgery, I tried Weight Watchers, exercise, and dieting," says Rheannon, who, at 5'2'', weighed 360 pounds before her surgery. "But I had difficulties losing the weight—I would lose but then I would gain it back."

This is a common experience, says Dr. Levy, who performed Rheannon's surgery. "Once you lose more than 10 percent of your weight, based on what your body wants you to be, it thinks you’re going into starvation mode," she says. "Your metabolism starts slowing and your hunger starts increasing because your body wants you to gain that weight back.... This is a hormonal and metabolic issue more than anything." In cases like these, when a patient needs to lose weight for health reasons, medical interventions for weight loss may come next.

obesity treatment strategies
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What doctors think of weight-loss medication and bariatric surgery

Prescription drugs are often added to the treatment plan—along with a balanced diet, exercise, and the lifestyle modifications mentioned above—when an obese person is still struggling to lose weight and keep it off. "Depending on the medical history of the patient, if their BMI is greater than 30, they may qualify [for medication]," says Dr. Surampudi. "Some select patients who have a BMI greater than 27 with obesity-related [health problems] may also qualify."

Many meds prescribed for weight loss—including phentermine, benzphetamine, diethylpropion, and phendimetrazine—interact with the nervous system to suppress appetite, says Dr. Garber, who adds that others help decrease the amount of fat absorbed from a meal (orlistat), or slow the amount of time it takes for food to empty the stomach, keeping hunger pangs at bay (liraglutide). These medications aren't exactly a simple fix, especially since many come with unpleasant side effects, like headaches, GI discomfort, and fatigue, in addition to more serious issues like severe anxiety, high blood pressure, a racing heart, or seizures.

However, the newest pharmaceutical option, approved by the FDA just last month, Plenity, is a first-of-its-kind weight-loss pill that takes a different approach. It's designed to help people manage their weight by filling the stomach with a gel-like substance. Each capsule is filled with a hydrogel that expands in the stomach when taken with a meal, making people feel full and helping them eat smaller portions. It's broken down in the large intestine and expelled from the body with food, and holds promise for unleashing fewer serious side effects than other drugs, since it doesn't enter the bloodstream or impact the body on a biochemical level. (Bloating, flatulance, and abdominal pain are the most commonly reported downsides of Plenity.) Another key difference is that it's FDA-approved for those with a BMI of 25 and above—in other words, it includes those who are considered overweight, rather than being limited for those who are considered obese. "It fills a huge gap in taking care of overweight patients besides diet and exercise," says Dr. Surampudi, who notes that it's still too early to tell whether this option may be more effective than the drugs currently available.

One thing that is likely is that like other weight-loss drugs, Plenity probably won't be a permanent fix for everyone. "In some studies, people regain the weight lost if the medication is stopped, especially if the person has not changed any lifestyle habits," says Dr. Surampudi.

"I always say that [bariatric surgery] is a tool—it’s not the answer to your problems."—Quinn, 32

Bariatric surgery is another option for some people—specifically those considered seriously obese (with a BMI greater than 40), or those with a BMI greater than 35 with associated health problems, says Dr. Surampudi. In addition to the sleeve gastrectomy Quinn and Rheannon underwent, gastric bypass is another option. For this procedure, a pouch is created in the stomach, and food is rerouted to a point further down the small intestine than it normally would be. "In our native anatomy, we eat food and that food almost immediately mixes with our digestive enzymes and juices," says Dr. Levy. "With a gastric bypass, we create one route for the food and one route for the digestive enzymes, and they meet up a little bit later in the GI tract." Because of this lag in digestive action, a gastric bypass patient absorbs fewer calories from the food they eat and their hunger hormones decrease. Gastric bypass is usually recommended for the obese patients with a BMI over 45.

"Bariatric surgery can help make [the transition to a healthy diet and exercise routine] easier," Dr. Surampudi says. It's also highly effective for long-term weight loss—data shows that patients maintain more than 50 percent of their initial weight loss up to 20 years post-surgery, and obesity-related health problems often subside at the same time. But again, it's not a magic-bullet solution. Although Rheannon has lost nearly 100 pounds since her July 2018 surgery, she says her weight still fluctuates. She also found it challenging to adjust to a new way of eating post-surgery. "Some people will eat when they’re bored, and when you have this surgery you can’t just eat like you used to," she says. This is because overeating after bariatric surgery can result in nausea, vomiting, and other unpleasant complications—and it can even lead the stomach pouch to stretch out over time, thus compromising the effectiveness of the procedure's intent. "You have to be mentally prepared. It was a good decision for me, but not everyone is going to have the mind-set that I had."

Quinn agrees with this sentiment. "I always say that [bariatric surgery] is a tool—it’s not the answer to your problems," she says. "If you have an unhealthy relationship with food, having weight-loss surgery isn’t going to fix that. You have to be willing to fully dive into it in every aspect of your life, for the rest of your life."

Doctors are on the same page about medicine and surgery both being helpful when treating a patient with serious obesity. That said, the options currently available aren't perfect. "There is still a lot we need to learn about weight loss, including preventing weight regain, who will respond to what therapy the best, and how to help patients through plateaus more effectively," says Dr. Surampudi. Healthy eating and exercise should always be the mainstays of any obesity-treatment plan—anything else is just "an additional tool" to be used when absolutely necessary, she says.

Dr. Levy adds that doctors need to become more proactive about helping patients address obesity before it leads to health complications. "Obesity works like any other disease. The earlier you treat it, the more successful you're going to be," she says. "Why do we need to wait until somebody has end-stage obesity to treat this disease? It’s not that you can never come back from it the farther along you get, but if we start talking about it earlier, it’ll make it easier to prevent [adverse health outcomes]."

Experts agree that it's worth talking to your MD if you want to lose weight and are having trouble getting there. They might refer you to a nutritionist or trainer who specializes in weight loss, or perhaps recommend an option that's more medical in nature. (For many people, these options are covered by insurance, says Dr. Levy.)

In Quinn's case, that conversation with her doctor changed her life: She's reframed her relationship with food, is now a regular at the gym, and has completed a triathlon and numerous 5Ks in the three years since her sleeve gastrectomy. "I believe you can be a body-positive person and still undergo weight-loss surgery," she says. "My size and my health are two different things in my eyes, and my body wasn’t going to remain healthy if it was carrying around 300 pounds."

Yes, you can love your body and still want to lose weight—here's how to walk that fine line. One obesity-prevention strategy that may surprise you? Having a healthy, long-term relationship

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