Obesity and weight loss

Debra L. Glasser, M.D.

Photo by Olympia Wedding Photographer | Loewyn Behold Photography

With signs on busy street corners for semaglutide (at Division and Capital Mall Boulevard), neighbors giving away clothes due to weight loss, and most of us knowing someone who has taken one of the new injectable drugs, it’s time to write about this topic.

 I offer professional reflection and opinion, not a comprehensive review. Regarding new treatments in medicine, I am a critical skeptic and adopt a "we shall see" attitude. The hype and promise of new treatments are seductive. Science is a slow process. It takes time to know if something new will work and be safe.  

The problem is, um, BIG!

Two out of 5 (or 42%) of US adults are obese compared to 30% only 25 years ago. Stigmatization and self-blame are painful for those who are overweight, plus the condition can lead to diabetes, high blood pressure, heart disease, cancer, kidney failure, infertility, joint pain, and more.

Obesity and overweight are health conditions of modern culture.

We humans are animals with Pavlovian reflexes (see food: salivate). Modern culture is one of excess, comfort, and convenience. Food cues and availability are pervasive. Ages ago, food was not in excess. Our biology is designed for survival and has not caught up.

Losing weight has never been that difficult. Maintaining weight loss has.

Remember calories in / calories out?

Weight Watchers, pre-prepared food plans, calorie counting, intensive exercise, the grapefruit and cabbage soup diets, etc. worked for most to lose weight, at first. Rarely was the loss maintained. Most regained more than they lost.

Ketogenic diets work for weight loss and better blood sugar control in diabetes. Are they sustainable? Rarely.

Psychologic and mental health techniques for weight loss

Overeaters Anonymous, behavioral modification, hypnosis, and conscious eating approaches work for some, to a point. Still, old habits and appetite drives come back like a boomerang.

Bariatric Surgery, introduced in the 1960s, seemed to be the answer. It initially worked for weight loss and improved diabetes control for most but failed for many over time. Surgery has better results than "conventional" weight loss methods in the first two years, but by 10 years >60% had regained their weight. Not great but still better than conventional approaches where 88% regain the lost weight or more. Some surgeries cause lifelong side effects.

This is still an approach used for those with serious obesity-related health problems or who are young.

Intermittent Fasting is a newer kid on the weight loss block. So far, I read of no safety concerns, it results in weight loss and improvements in metabolism (blood sugar, cholesterol) and has been sustainable for some. Stay tuned for more on this approach.

All weight loss programs work because people eat less, for a while

Despite religious-like beliefs and fanaticism about diets, health, and weight, none have proven long-lasting success for all.

Nothing works in the long run because we don’t yet understand the forces driving appetite and hunger.

We do know that whatever successful changes one undertakes for weight loss need to become a way of life for weight loss to be sustained.

Uncertainty indicates a lack of understanding. Weight balance, set points, loss, and gain are complicated. They involve the physiology and psychology of hunger and appetite. Physical, hormonal, metabolic, mental, and psychological factors are at play. Habits, whatever their cause, die hard. The keys to changing those complex forces for eating remain elusive.

Drumroll…enter Glucagon-like Peptide 1 Agonists (GLP1s)

– will they be the game-changers?

 Semaglutide (Ozempic, Wegovy), dulaglutide (Trulicity), liraglutide (Victoza, Saxenda), exenatide (Byetta and Bydureon) and more are GLP1 agonists. They act like glucagon in the body. They turn off appetite and slow down stomach emptying. You eat less and lose weight.

 These drugs are advertised all over the place. I have been scanning research on these medications with interest. A drug breakthrough in obesity treatment is something worth paying attention to. It will help our nation’s health and be a major money maker. It already is.

This class of drugs was developed to control diabetes. Taking these drugs results in significant improvements in blood sugar control that can be lifesaving. They cause major weight loss, up to 15% of body weight or more. They have been game changers for diabetes.

Because of their surprising effect on weight, they are now being used extensively for weight loss (without diabetes) along with plenty of fervor and hype. This is despite their cost of >$1000 per month without insurance coverage! Hence, they are now in short supply.

Who should get these drugs?

Diabetics are losing feet, nerves, kidneys, and vision. Obese and overweight people with and without pre-diabetics have problems waiting to happen and are willing to pay a lot to lose weight. The "weight loss industry" has always been a big money maker. Dealing with scarcity is not our culture’s forte.

Telephone and internet prescribers as well as compounding pharmacies are selling and mixing up these drugs for people to self-inject.  Do a Google search. What is a reputable source? How can I (or you) know? It’s risky. Without adequate training, accidental overdoses are sending people to the hospital with symptoms such as vomiting that can last a week or more because these drugs work that long in the body.

 And like everything that came before, it appears that for most to sustain weight loss and maintain a lower appetite, these medications need to be taken long-term.

Long-term dosing is being worked out, but still. Lifelong?

The potential for these drugs is enormous even as the science and safety are developing. They are helping many right now. They have propelled science forward in understanding the drivers and potential treatment of all causes of being overweight. Hopefully, this will lead to long-term and curative solutions for this modern affliction.

Meanwhile, what can you do?

• Take your time. Learn, ask, study, get professional guidance, and think before you act. Do you need to lose weight? Why or why not? Reacting out of fear and desperation is neither wise nor safe. Losing weight is important for health but not urgent. Weigh your options.
• Nutrition matters. Support farmers. Eat real food – not highly processed foods and beverages that are sugary, made with fake hydrogenated fats, artificial sweeteners, and other chemicals that increase shelf life and palatability, not nutritional value. Processed foods are designed to be irresistible and deliver enormous profits for manufacturers. Research is discovering an ever-growing list of adverse effects these non-real junk foods deliver to our bodies and minds.
• Moving and exercise matter – aerobic (walking), strength (weightlifting), and flexibility (yoga). Work in your yard, shovel bark mulch, carry the groceries, mow the grass under your feet, walk to the store, and take the stairs. It doesn’t have to be complicated or expensive, but being physically active does need to be a regular habit for health.
• Mental health matters, too – take care of your mind and emotions, deal with stress, and get help if you need it.

 Bon Appetit! Balanced, healthy, nutritious, and delicious!

Debra L. Glasser, M.D., is a retired internal medicine physician in Olympia. Got a question for her? Write drdebra@theJOLTnews.com