Alternatives to Surgery: Medical Weight Loss

If you can lose weight AND SUSTAIN your weight loss without surgery please do not have weight loss surgery. Weight loss surgery is not for everyone. But you are probably considering weight loss surgery because you have been on many diets that have ultimately failed.

Why diets do not work. Severely overweight people are some of the most successful dieters around. Many have had success in losing many dozens of pounds only to realize that the weight loss is impossible to sustain. Taking dietary histories on our patients reveals that most have been on 5, 10 or more successful diets. That success unfortunately is temporary. Why is this? It is because the body naturally resists starvation. This mechanism sustained humans when food was scarce and it was not known when the next meal was coming. In modern day America, food is easy to attain and always plentiful, so this body mechanism in those who are susceptible becomes pathologic, leading to morbid obesity.

When you restrict your calories, your body decreases your metabolism by nearly 30%. Dieters can sustain this for a period of time, but weight loss is limited due to this “starvation metabolic response”. The dieter finally gives up and returns to their usual eating habits and not only regains the weight lost during the diet, but gains additional weight contributing to the weight gain cycle that leads to obesity. This is often referred to as “YO-YO” dieting. Morbidly obese patients often tell us that they have stopped dieting, because it was making their obesity worse, and it was.

Obesity is a lifelong problem. The fact is that obesity is a lifelong disease, and any attempt to treat morbid obesity should be a lifelong solution. The world’s medical literature shows and we believe the only sustainable way to achieve weight loss in a morbidly obese patient is by providing the patient an effective tool, weight loss surgery, to make that lifelong difference. The National Institutes Of Health, after studying obesity stated “surgery is the only way to obtain consistent, permanent weight loss for morbidly obese patients.”

Medical weight loss. The best and most recent medical scientific evidence for how best to achieve medical weight loss (without weight loss surgery) is summarized in the National Heart, Lung, and Blood Institute (NHLBI) Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. After this very careful study by worldwide experts, they advised that weight loss and maintenance therapy should use a combination of low-calorie diets, increased physical activity, and behavioral therapy. A number of insurance companies have recently developed criteria that follow NHLBI recommendations very closely.

What about commercial weight reduction programs, such as Weight Watchers ®, Jenny Craig ®, etc.? People just do not stick to them. See the “High Attrition of Commercial Weight Reduction Programs” graph. Many of these programs promote other components of successful weight loss programs such as exercise and behavioral management. Other diets such as the Atkins, the Scarsdale, Southbeach, etc., etc., do not fare any better. The NHLBI researchers were not impressed with these diets and these programs.

Medical Weight Loss Therapy in the Morbidly Obese. These scientifically sound and practical NHLBI strategies form the foundation for lifestyle management across all body mass index (BMI) ranges, including individuals with body mass indexes over 35. However, because most of the clinical trials reviewed in this summary present outcome data for individuals within a BMI range of 30–40, these results cannot necessarily be assumed they apply to individuals with extreme obesity. The evidence that NHLBI strategies alone are effective in persons with body mass indexes above 35 is limited. The truth is that there are NO published studies demonstrating significant SUSTAINED weight loss in the MORBIDLY OBESE. But, insurance companies often require a trial of formal medical weight loss therapy despite the lack of evidence that it works in the long term. We think it helps them assure that the patient can follow the necessary diet and lifestyle changes after weight loss surgery.

Medical Weight Loss Therapy: The details

1. Medical evaluation
2. Nutritional evaluation and education
3. Dietary therapy (low-calorie diet)
4. Increased physical activity (exercise program)
5. Behavioral therapy
6. Consideration of FDA-approved weight-loss drugs

1. Medical evaluation by a licensed physician / provider

Medical weight loss therapy has to be supervised by a medical practioner.  (We cannot do it as weight loss surgeons but practioners associated with our program may soon offer this service).  Your medical provider can download a practical guide to the NHBLI recommendations here. 

Your Medical Provider should have you weigh in and visit at least once a month or more often for at least 6 months. 

2. Nutritional evaluation and education by a registered nutritionist or dietician.

The initial evaluation and assessment as well as the diet should be carefully documented. 

Ideally the patient sees the nutritionist/dietitian once a month or more often for at least 6 months.  Long-term changes in food choices are more likely to be successful when the patient’s preferences are taken into account and when the patient is educated about food composition, labeling, preparation, and portion size.

3. Dietary therapy (i.e., Low-Calorie Diet)

Note: Diet programs/plans alone, such as Weight Watchers®, Jenny Craig® and similar plans, are not considered physician-directed weight-loss programs. You are not discouraged to try these programs, but they will not often “count” for most insurance companies.

Very Low Calorie diets (VLCD) have not been proven to be better than Low Calorie Diets (LCD). VLCDs are defined as hypocaloric diets containing 800 Calories (kcal/day). Initial weight loss with VLCDs is profound, however these diets are difficult to stay on. See the graph of weight loss on the VLCD: initial weight loss was good, but long term failure rates were high.

Ultimately, Low Calorie Diets (LCDs) have been shown to be as good as stricter diets. With Low Calorie Diets, Caloric intake should be reduced by 500 to 1,000 calories per day (kcal/day) from the current level. IN general, diets containing 1,000 to 1,200 kcal/day should be selected for most women; a diet between 1,200 kcal/day and 1,600 kcal/day for men. This will produce a recommended weight loss of 1 to 2 pounds per week. Although dietary fat is a rich source of calories, reducing dietary fat without reducing calories will not produce weight loss. These diets are designed to replace usual food intake, are relatively enriched in protein, and include the full complement of micronutrients. (By the way the weight loss curve with Low Calorie Diets looks very similar to the Graph above, long term failure is the rule.)

4. Increased physical activity (i.e., exercise program)

You should ideally involve a personal trainer to increase safety and efficacy of the exercise program. Your medical practioner should assess you for the safety of starting an exercise program before you begin. Physical activity (exercise) appears to be most important for maintenance of weight loss. It builds metabolically active muscle, which will help maintain the weight loss by burning calories even when you are not exercising. Physical activity also reduces the risk of heart disease more than that achieved by weight loss alone. All adults should set a long-term goal to accumulate at least 30 minutes or more of moderate-intensity physical activity on most, and preferably all, days of the week.

It is important that you keep an exercise log and that it is reviewed by the medical practioner, who documents that they have reviewed it.

5. Behavioral therapy

Behavior therapy is a useful adjunct to planned adjustments in food intake and physical activity. Behavioral therapy incorporates strategies to promote changes in diet and exercise through acquisition of skills, motivation, and support. The medical provider provides some of this and should document the discussions. The dietitian and the personal trainer also provide much of this, and should try to document this. On occasion a mental health professional or counselor can and should be involved to help the patient achieve success. Support groups are very much recommended, if they are available.

“Behavioral Therapy” is really the documentation of encouragement and strategies provided by your health care provider, the dietitian, the personal trainer, your mental health provider, and / or a support group. Documentation of these sessions would be ideal.

6. Consideration of pharmacotherapy with FDA-approved weight-loss drugs

Pharmacotherapy is used as an adjunct to diet and physical activity for patients with a BMI >30 or those with a BMI > 27 with concomitant obesity-related risk factors or diseases. These drugs may not provide profound results, but they may be a recommended addition to a comprehensive weight loss program.

Two medications, sibutramine (Meridia: FDA approved in 1997) and orlistat ( Xenical: FDA approved in 1999), have been studied in multiple randomized controlled trials, mostly ranging from 6 months to 2 years in length. Few long-term trials exist beyond 1–2 years, raising concerns about efficacy and safety. These drugs should be used and were studied in the context of a treatment program that includes the elements described previously—diet, physical activity changes, and behavior therapy. The weight loss that these drugs can produce is no more than 5 to 10% of excess body weight lost in 6 months. The best studies (on sibutramine) state that over 50% of the patients stopped the drugs and less than half of those remaining in the study kept the weight off in 2 years. If a patient has not lost 4.4 pounds (2 kg) after 4 weeks, it is not likely that this patient will benefit from the drug. Weight loss is not sustained when medications are discontinued. No other drugs meet FDA criteria for weight loss drugs and at the present time, this is the best that medical science has to offer.

Sibutramine (Meridia) is a serotonin norepinephrine reuptake inhibitor that functions as an appetite suppressant. Sibutramine is contraindicated in obese patients with high blood pressure and cardiac conditions.

Orlistat (Xenical) competitively inhibits intestinal lipases and blocks the absorption of approximately 30% of dietary fat. Orlistat can produce oily, difficult to control discharge, which can make it difficult to continue.

Phentermine first received approval from the Food and Drug Administration (FDA) in 1959 as an appetite suppressant for the short- term treatment of obesity. Phentermine was used in combination with Fenfluramine called Phen-Fen, but this combination was removed from the market due to cardiac concerns. Phentermine is still used by some physicians, but there are no recent studies on the efficacy and safety of Phentermine. Phentermine is an amphetamine-like drug, and is related to Ephedra. Ephedra was just removed from the market by the FDA due to safety concerns and was a component of a number of over the counter weight loss drugs . There remain similar concerns with Phentermine and it is not recommended, particularly in patients with high blood pressure and cardiac conditions.

¹Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1):1-20.

²Diets, drugs, exercise, and behavioral modification: Where these work and where they do not. R. Kushner / Surgery for Obesity and Related Diseases 1 (2005) 120–122.

⁴Gastrointestinal Surgery for Severe Obesity. NIH Consensus Statement 1991 Mar 25-27;9(1):1-20.

⁵National Heart, Lung, and Blood Institute (NHLBI). Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. The Evidence Report. NIH Pub. No. 98-4083. 1998 Sep. Accessed Apr 16, 2005. Available at URL address: http://www.nhlbi.nih.gov/guidelines/obesity/ob_home.htm

⁶Effect of sibutramine on weight maintenance after weight loss: a randomized trial. STORM Study Group. Sibutramine Trial of Obesity Reduction and Maintenance. Lancet. 2001 Apr 21;357(9264):1287-8.

⁷http://nccam.nih.gov/health/alerts/ephedra/consumeradvisory.htm