One of the most difficult problems to deal with in the practice of medicine – is weight loss. The management of this medical problem ranges from those who are grossly obese (BMI over 35+; 250+ pounds) to those who are putting on extra pounds as they approach age 45 to those who want to lose a few pounds to get back into their formal wear for the big gala.
This wide-ranging problem is further complicated by the not-so-subconscious bias against overweight people as friends or employees – to the adamant social movement demanding unqualified acceptance of obesity as “normal” and of no medical consequence.
Enter the newest medical effort to manage obesity – the type-II diabetes medicines, semaglutide and its cousins in various forms. Originally intended to treat type-II diabetes, these medicines were recently approved for weight-loss therapy. Why? Semaglutide suppresses appetite and decreases blood sugar levels resulting in an average weight loss of 6% in three months to 15% of body weight over a 15-month treatment period. This kind of weight loss engenders multiple improvements in health – improvement in sleep apnea, lowering blood pressure, decreases in fatty liver disease, decreased risk of cardiovascular disease, decreased risk of stroke, besides improvement in type-II diabetes and all its risks – all of which are to be expected with these significant weight loss numbers.
So, what’s not to like in semaglutide? Like all medicines, semaglutide has significant side-effects which must be managed by appropriate medical providers. Because the medicine mimics naturally occurring protein chains that regulate bowel functions, most side-effects are bowel problems which are usually controlled with other medications or by regulating the dosage of the drug. Other more serious side-effects – pancreatitis, acute kidney injury, worsening depression or suicidal ideation – require cessation of the medication.
But the greater problems are the unrealistic expectations – even by medical professionals – of safe and effective weight loss without lifestyle change. There are no magic pills that can correct a life of high calorie eating and low levels of activity. Yes, the medicine will suppress the appetite, resulting in weight loss. But when the medicine is discontinued, the old lifestyle patterns will return along with regaining all the weight lost. Nothing was learned; nothing will change.
Every effective weight loss program must include – with the medicine – retraining the habit patterns and addressing the psychosocial problems that led to overeating, creating the obesity problem initially. The complaint is that these medicines – to be permanently effective – must be continued for a lifetime. True – unless these habit patterns are retrained, and a new lifestyle related to food and exercise are learned. At that point the medicines can be gradually discontinued, and the new lifestyle can take over the maintenance of the new weight and renewed wellness.
The second complaint concerning the long-term use of these medicines is that rapid weight loss is usually 25% bone and muscle weight loss. This is compounded by the fact that being obese requires stronger bones and muscles to move such a large weight from place to place. Lowering weight decreases the stresses that strengthen bones and muscles. The obvious answer is to offset the loss of weight with increased activity – stretching and balance training, weight training, and cardiovascular exercise – to continue the good stresses that strengthen bones and muscles. All successful weight loss programs include these modalities – with or without the medicines.
The third complaint is the fear of nutritional deficiency from lower calorie intake. Again, the obvious answer is dietary, nutritional counseling and training. Calorie dense foods – foods that contain lots of calories per portion size – usually contain highly refined carbohydrates, extra sugar, lots of fats – and very little nutrients, like vitamins, minerals, and especially fiber. Healthy foods of whole, unrefined grains, legumes, vegetables (without the sauces), fresh fruits (without the sugary syrups) are all high in nutrients and much lower in calories. Even with smaller portion sizes, there is absolutely no reason to assume that eating fewer calories will result in poor nutrition.
And finally, the concern about protein deficiency. Food intake of whole grains, legumes, vegetables, fruits, with nuts and seeds supplementing them provides adequate protein intake for normal-sized, normally active adults. Protein requirements are greatly exaggerated even among the professional dietary and weight-loss community. If little or no muscle loss is experienced due to increased physical activity, then no increased protein is required above that which is normally needed – 45 grams a day for males and 35 grams a day for females.
Using common sense and scientifically proven methods of a complete rehabilitation program – activity and dietary counseling – to offset changes due to weight loss can lead to a successful correction in the weight without the necessity of continuing these weight loss medications for a lifetime. No magic pills. Just good common sense.
