Thou seest I have more flesh than another man, and therefore more frailty (Shakespeare, Henry IV)
Introduction
In an ideal world, we would only eat the calories we need and no more. Similar to most animals (not the hippo), we would all be svelte, athletic specimens. However, we live in a zoo not a jungle; our departure from traditional ways of life has seen an explosion in overweight and obesity to the point that being normal weight in western countries is statistically the minority (especially Australia which is now the fattest country on earth).
Gaining and carrying weight is distressing. Not only does it make us feel bad about ourselves and how we look; it also comes with serious health consequences. Not least, it makes us sluggish and tired. Unsurprisingly, there is a multi-billion dollar industry aiming to help people lose weight; much of this is unscientific and does not address the root causes of weight gain.
Weight loss is a difficult area in medicine and represents a complex interaction of environment, genetics, nutrition, hormonal factors and many more unknown interactions all intersecting at a complex level.
Before 1950, obesity was almost never heard of. Few pre-industrialised societies have any obesity or diabetes. This gives us a clue on where to look for the root causes of obesity.
Whilst it is true that eating less and eating ‘well’ is the mainstay of weight loss, the reality is that our underlying vitamin, gut and hormonal health are far more complex than any simplistic calorie counting or macro counting diet can address.
Put simply, vitamins and hormones matter when fixing weight problems. Many diets will often make this worse by allowing the wrong kinds of foods (processed) or even restricting dietary fiber and thus worsening the hormonal decline which contributes to a sluggish metabolism.
There is no simplistic or easy solution to weight loss; this is the ultimate case of ‘fix the body’ and the weight will sort itself out. In an ironic way, you have to eat yourself out of obesity. Irrespective of any other measure, if you do not eat a diet high in unprocessed vegetables you will be at high risk to gain weight even if you drop carbs and exercise like a maniac.
Healthy weight management requires a holistic approach to lifestyle and idealised internal health.
What is the right weight?
A healthy BMI (heigh and weight as kg/m2) is between 20-25 for caucasians and 18.5-23.5 for east Asians. Body composition should be taken into account too. A high fat ratio and lower muscle mass, even for a ‘normal’ BMI, has similar negative health outcomes to obesity. Conversely, somebody who has a higher BMI but plenty of muscle mass tends to stay quite healthy.
What is more important: Diet or exercise?
Diet is probably more important than exercise. Whilst exercise can contribute to a marginal increase in our total energy output (and is good for us in many ways), the concert of metabolic hormones and signals in the body matters more to fat volume.
It is important to be active, but you do not need to be an athlete to have a healthy BMI. Asia has some of the thinnest populations in the world; this is mostly achieved by regular gentle activity but a focus on a better diet. Conspicuous high intensity exercise is no substitute for diet.
In general, if a body is under stress from toxins, oxidative stress, methylation issues, malnutrition etc. then the tendency is for the body to lower the metabolic hormones (testosterone, thyroid, leptin, adiponectin) in favour of pro-obesity hormones (insulin, ghrelin).
What this means is that a stressed body will try to ‘save calories’ and store fat rather than ‘spend them’ and burn it off. In this setting, the metabolism slows down, we burn less energy and tend to stack on fat.
This will often impact your weight far more and highlights the need for a ‘total health’ approach to weight.
How to get started on weight loss?
Approaches to weight loss vary and may or may not involve seeing your doctor.
It does help to be able to do blood tests to check on your metabolism. Checking various hormones such as estrogen, progesterone, testosterone, growth hormone, thyroid and insulin will tell us more about whether your hormones are healthy and your metabolic rate is higher and appropriately wanting to burn calories.
In a nutshell, if a hormone is low, it needs to be addressed or replaced to normalise the metabolic rate.
Blood tests help give us a deeper look at how your body responds to the environment and nutrients.
By using blood tests and genetic tests, it may become appropriate to consider medical treatments in managing weight loss rather than just counting calories.
Does counting calories and ‘macros’ work?
Counting calories and predetermining the ratio of protein, carbohydrate and fat is a bit like filling your car boot with petrol, putting oil in the glovebox and having four different sized tyres.
From a distance, it is what the car needs; but it’s all wrong.
The same is true for our nutrition. Our bodies did not evolve to have an algorithm for food. They evolved to make the best use of food hunted and gathered in a pre industrialised habitat.
Calorie and macro counting discount the role of the gut microbiota. Many of our vitamins actually come from dietary fiber. Dietary fiber is also critical for hormonal regulation of the body, antioxidation and for detoxification of byproducts. When there is insufficient good gut bacteria and dietary fiber, a person is much more likely to have lower hormones and become obese.
The issue with calorie counting and macro counting is that they do not focus on the ‘type’ of food we eat. Whilst calorie restriction might very well be helpful, if it leads to a lack of dietary fiber and vitamins, the metabolic rate and associated hormones will drop. Similarly, macro counting might not help unless it involves eating lots of dietary fiber so that our good gut bacteria can thrive and detoxify our body.
Calorie and macro counting are a blunt instrument. They are not sophisticated enough to give the body what it needs to thrive. A better approach is to understand how the gut works and aim to eat healthy, organic foods that are good for our body in a number of ways. Highly processed foods are uniformly the cause of obesity; they do not leave us feeling full, they provide very little dietary fiber and nutrition and are energy dense.
Stick to the broccoli and not the fad diets!
Do medications for weight loss work?
There are several medications that are commonly used for weight loss if deemed appropriate by your doctor. Diet and exercise are the best first choice agents, however metformin (a diabetes medication) may be used if you have high insulin.
Furthermore, medications such as topiramate, naltrexone, wellbutrin and duromine have been used to suppress appetite and manage cravings. It is important to address alcohol intake.
More successful agents for weight loss include semaglutide, or Ozempic (available also as Wegovy in a higher dose now), which are diabetes medications. These medications are injected and studies show weight loss ranging from roughly 4.8-10kg.
It should be emphasised that these medications work differently in all people and are not a first line for weight loss but are used if your doctor considers it clinically appropriate in light of the total picture.
What other habits are important?
Diet should include vegetables and research shows the importance of exercise and high quality sleep. Be wary of beverages which contain many calories such as sweet drinks and alcohols. The skills of a dietitian are most useful.
REFERENCES
Astrup A, Carraro R, Finer N, et al. Safety, tolerability and sustained weight loss over 2 years with the once-daily human GLP-1 analog, liraglutide [published correction appears in Int J Obes (Lond). 2012 Jun;36(6):890] [published correction appears in Int J Obes (Lond). 2013 Feb;37(2):322]. Int J Obes (Lond). 2012;36(6):843-854. doi:10.1038/ijo.2011.158
O’Neil PM, Birkenfeld AL, McGowan B, et al. Efficacy and safety of semaglutide compared with liraglutide and placebo for weight loss in patients with obesity: a randomised, double-blind, placebo and active controlled, dose-ranging, phase 2 trial. Lancet. 2018;392(10148):637-649.
Perreault, L. Obesity in Adults: Dietary Therapy. UpToDate. Waltham, MA: UpToDate: 2020. www.uptodate.com. Accessed. June 21 2020.
Perreault, L., Apovian, C. Obesity in Adults: Overview of Management. UpToDate. Waltham, MA: UpToDate: 2020. www.uptodate.com. Accessed. June 21 2020.
Pi-Sunyer X, Astrup A, Fujioka K, et al. A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management. N Engl J Med. 2015;373(1):11-22. doi:10.1056/NEJMoa1411892
