Possible solutions for obesity

There are some tested methods against obesity, and the most effective ones are:

1. Physical exercise
2. Dieting
3. Obesogenic environment
4. Surgery

Weight loss is the result of a negative energy balance (energy intake is lower than the energy expediture). For a successful weight loss, you need to decrease energy intake through diet, or to increase energy expediture through exercise. Other less used alternatives are using a fat digestion inhibitor like Orlistat or adjustment to lose more energy via feces.

This is an easy solution only in theory, but hard to put in practice. Creating long lasting habits is a must in this case, and lacking this skill leads to failure (failing to prepare is preparing to fail), In order to lose weight through diet you need to adopt a hipocaloric one, and the result is fat lose over time. Seems a bit contradictory, but you can lose weight even eating burgers and stake, as long as the energy balance is negative. Warning: any claim of fat loss diet without reducing the energy intake is a scam. The biggest the cut, the faster the loss, but we need to not forget that eventually we gonna hit a plateau as having less fat means having less weight, so the basal metabolic rate will also decrease. The magnitude of the fat loss is determined by the overall energy deficit created as a result of being on diet. Monotonous diets tend to be highly effective in causing short term fat loss due to the declining satisfaction resulting from the consumption of only one specific type of food, even if it is one that we like (we are talking here about hedonic adaptation - one chocolate is nice, twenty chocolates at once are awful). But, because monotonous diets are boring, is hard to stick to them and not return to old food habits.

In conclusion, the higher overall reduction in energy intake, the higher is the fat loss. Fasting is the most effective way to lose weight. Major restriction in choice of foods lead to reduction in energy intake due to sensory-specific satiety (hedonic adaptation). Dieting and weight loss cause increased appetite and hunger, being the biggest problem after a diet (that's why we put back the weight) and we need to mentally prepare and use our will until balance is reached once more (you need to give your body time to adapt). A high protein diet promotes satiety and is the most effective solution to suppress the hunger feeling. The improvement in health parameters after weight loss are determined by the amount of fat lost and not by the method used to lose weight. Long term success rate of weight lose is 10%, and people dieting ultimately fail and regain back the weight and even add some more.

Dietary fat and weight maintenance reached a peak in the Eighties, targeting fat intake to achieve weight lose because of the higher caloric density (9 kcal as opposed to 4 kcal for carbohydrates and protein). Fat was branded evil, but they ignored the importance of the daily total amount of calories (a positive energy balance with a lower percentage of fat intake will still make us to gain weight). As the fat-free meals consumption increased, with them still having loads of carbohydrates, later they started to brand carbs as being bad and they started to eat the good fats, once again ignoring the calories. There is no miracle pill or miracle food, if you keep a positive energy balance. No herbal tea, no lemon, no sauna belt, if it is too good to be true, it is a scam.

Physical exercise is an alternative or complementary approach to lose weight. The results tend to be lower than predicted as we partially compensate for the increased energy expediture by eating a bit more. Exercise done long enough helps to maintain weight, but physical exercise works slowly over time, while diet effects are shown faster.

Changing the obesogenic environment is another option. At least 30% of the global population is overweight or obese, all this increasing the chances of diabetes, heart diseases and cancer. Obesity related drugs are interfering with the appetite and food regulation (these processes are very centrally regulated, in some parts of the brain), leading often to unexpected side effects. There are locally active versions such as Lipase inhibitors (gastro-intestinal region), but they have limited effect and less side effects. Drugs development and research is not the answer (they are very expensive solutions).

We got the bariatric surgery, which is good and effective, but it is also very expensive and require lifetime supervision. If you often heard that obese people are to be held accountable for their problem, keep in mind that this is a myth, as much untrue as the idea that poverty can be avoided if you work harder. There are viable solutions, but obese people need extensive support. Obesity is a normal response to an abnormal environment (we are talking about food factors, socio-economic factors, cultural factors and much more). Add the genetic factors to all those external ones to complicate it even more. Obesogenic environments are conducive to obesity, and differences were observed between countries, even cities or neighborhoods. We have the Amsterdam example, where there are neighborhoods with less than 10% obesity and neighborhoods with more than 30% obesity. Even more, 75% of the obese children live in 2-3 neighborhoods out of 15. They are unequally distributed, , with lots of traffic, little opportunities of physical activity, unhealthy food at schools or promoted by intense marketing. The tendency to obesity starts early in life, degrees of obesity can be seen at 5 months already.

Possible solutions to deal with this are dual: micro-environments like schools, homes and neighborhoods oriented healthy lifestyles, macro-environments where price of the healthy food is acceptable, education systems and nation-wide supported programs (to teach how to eat less and exercise more - creating opportunities to be physically active and to have available and atractive healthy choices of food.

Short term interventions based on individual advice are not very effective, as they work on short term and then relapse. Long term interventions and strategies as the one aiming to drink more water did not work either, even after removing vending machines from schools, because 85% of sugary drinks come from home. The education of the family could be the key. One of the most effective strategy is to educate for the first 1000 days of life, young parents education combined with information refresher session periodically as starting early and taking a lifetime approach seems to be the best option.

Lasting lifestyle changes are extremely difficult for everyone, and the people with excess body-fat are not an exception. Even if you know very well what to do, in order to change your lifestyle and adopt a healthy eating with better activity patterns, you need to learn how to get rid of the bad habit and how to create a lasting good habit. I would mention here Charles Duhigg's book "The power of habit". Most of the cases, the changes in food intake and activity level are not sustained long enough to achieve the desired effects. Because of that, many of them turn to medical professionals for advice. Obesity as a health problem is a potential source of revenue for drug industry, and drugs come and go, full of promises, but no solution was found to truly work. Combined with lifestyle changes, they offer limited help, shredding of up to 10% of the body weight. Most of them work by curbing appetite and hunger, but they usually got many side effects, the damage done outweighing the benefits. You cannot expect to specifically reduce food intake without affecting many other processes of the human body.

The overall limited effectiveness of the weight loss drugs will introduce the possibility of bariatric surgery to us. What is that, you will ask? Bariatric surgery means the removal of parts of stomach and small intestine to induce weight loss. This is a very popular option lately, it is hugely effective in weight loss and as a side effect of solving the obesity issue, many diseases associated with it are ameliorated or even cured. Mortality due to obesity is dramatically decreased after bariatric surgery, and, even if we do not know really well how it is working, we believe that excessive stretching of the stomach leads to early satiety and reduced meal size. Defective food absorption is of minor importance, but we have changes in the release of certain hormones related to food intake and changes in taste sensation. We can see immediate improvements in health parameters such as blood glucose levels even before the weight loss. The general agreement is that the sudden negative balance is the main mechanism responsible for the rapid changes in metabolism. However, it should not be recommended and used only as a last resort for those facing immediate health risk and for who the other less invasive options have failed. They need to be carefully assessed as bariatric surgery can fail if is not used in conjunction with healthy lifestyle changes. Also, it is ineffective for people suffering from some underlying psychological disorder that caused obesity as a side effect. In order for bariatric surgery to succeed, the patient needs to receive dietary counseling before and after the surgery, and to learn and use an effective strategy combining diet with exercise.

Next and last post of this section will be about nutrition and sport.
Have a nice day!

G.