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Our country is obsessed with weight and weight loss. No surprise as over 50% of the country has a BMI (body mass index over 30) BMIs can be misleading, however, as tall, heavily muscled men can have BMIs in the 40 range. There are at least 50 weight loss programs not including the HCG diet (at one point I worked with around 90 HCG patients). The components of an "effective" obesity management program include diet and physical activity (together) followed by behavior modificatio, then anti-obesity medications and lastly surgery. Before addressing weight loss, and having addressed lifestyle, other contributors of weight gain need to be addressed including estrogen dominance and stress related i.e. elevations in cortisol both of which cause abdominal obesity, hypothyroidism, genetics propensity, imbalances in the 2 hormones that directly impact fat deposition and hunger (gherlin/increases hunger and fat deposition, and leptin/decreases hunger and fat deposition), and the gut microbiome, specifically akkermansia which is critical for addressing metabolic syndrome. When looking at lifestyle the various components of appetite must be taken into consideration: Hunger (the drive to consume), Satiety or the end state of satisfaction, fullness (the physical feeling experienced in the gut, cravings, satiation or negative feedback leading to meal termination, and sensory pleasure elicited by contact with food. Until recently, I was unable to find a probiotic with akkermensia, however, a company started marketing one. Also, until recently, there was nothing on the market to depress gherlin until a company called integrated peptides came out with an oral peptide specifically for weight loss. Other than commitment, why is it so hard to loss weight? In my experience most weight loss programs fail due to lack of consistency and commitment. The simple answer is tug of war between trying to lose weight via decreasing calories and increasing activity and weight gain due to a decrease in metabolism and an increase in hunger hormones like gherlin. The complex answer is the interplay between food, neurotransmitters, the vagus nerve, inflammatory markers, etc. and the hypothalamus, (the center that drives most endocrine function).

Why do we care about losing weight? The answer should be obvious, health. Obesity leads to sleep disorders, inability to be active and impaired mental health, promotes insulin resistance and beta cell (pancreas) decompensation leading to type 2 diabetes which then results in medication induced weight gain, neuropathy and decreased activity, hypoglycemia and stimulation of food intake. "Vicious circle". This is just the beginning. The burden of excess fat results in knee arthritis, obstructive sleep apnea, GERD, urinary incontinence, high blood pressure, angiogenesis (encourages cancer growth), immune function effects inflammation in general and reproduction (PCOS and fertility)

What are the benefits of weight loss for diabetics? A 10% weight loss (abdominal fat and waist circumference) improves the lipid profile, improves insulin sensitivity and blood glucose as well as decreasing inflammatory markers. A study looking at diabetes remission as per achieving and HbA1c of less than 6.5% revealed that a 15 kg (2.2pounds to a KG) loss resulted in over a 70% change, 10-15kg loss/57%, 5-10kg loss/34% and 0-5kg loss 7%.

While I am not an advocate of anti obesity meds, I need to address the purpose of anti-obesity medications. To impact the appetite dysregulation of the disease, supports adherence to lifestyle interventions by helping patients adhere to a lower calorie diet and changing their relationship with food and to facilitate weight loss and improvements in health. They are usually indicated for patients with a BMI greater than 30. I feel I should touch on the latest weight loss drug craze. These are the GLP-1 RAs, the most popular being semaglutide which is given SQ weekly (although there is an oral form) Weight loss of 20% or more can be achieved over weeks to months. The downside to this class of drugs are two fold, an extensive side effect profile (I strongly recommend to all my patients that prior to starting any drug to review the side effects), and the expense which could run to hundreds and even thousands of dollars, with the understanding that all these drugs must be continued. If stopped (as show with studies with semaglutide) there is a progressive weight gain.

As a last ditch effort there are bariatric surgical procedures. The 3 most common are a sleeve gastrectomy, a Rous-en-y gastric bypass and a duodenal switch. Obviously any surgery has its downside as does these 3. Other than surgical complications the biggest concern is nutritional deficiencies. Depending on the procedure they may include iron, thiamine, calcium B12 folic acid and protein.

At the end of the day, everything, other than committing to a weight loss lifestyle, in my opinion and experience, is doomed to failure.


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