Managing Obesity: Is Lifestyle Modification Alone Sufficient?

Introduction: Obesity is common and rising

Based on National Population Health Survey Singapore in 2022, 11.6% of Singaporean residence between the age 18 to 74 years are obese, with at least 40% of population is overweight. The prevalence rate is increasing over the years in Singapore following progressive improvement of socio-economy of the local population, better lifestyle and more palate choices. Obesity remains more commonly seen in men compare to women. 

Why do people struggle with weight loss despite lifestyle management?

Obesity is now deemed as a chronic medical condition which is still poorly understood. It is believed that the complexity and recalcitrance in management of obesity can be associated with genetic susceptibility, a person's behavioral and cultural background, socio-economy influence or even possible underlying medical conditions.

It is not uncommonly heard of an obese individual tried aggressive lifestyle management- with dietary modification and exercise regimens resulting in initial drop of weight then overtime the weight stops dropping and reaches a plateau, in some, one may even regain weight over time.

1. The Set Point Theory
   The body has an innate defense homeostasis mechanism to safeguard us from losing weight. Set point is there to ensure we are healthy, and our weight is not dropping excessively. The same physiological effect exists for our body's blood pressure and sugar control. The inborn set point ensures the body's weight, blood pressure, sugar and etc are maintained in our 'usual' and 'normal range'.

   The nerve-hormonal axis in our brain regulates the set point, maintaining our body's metabolism by controlling the adipose (fat tissues) to be utilized more (or less) depending on body's requirement.

   Whenever we are proactively losing weight with exercise or mindful eating, the body will attempt to keep our weight at the usual range by hormonal adaptation, ensuring we are hungry and encouraging us to eat more. As a consequence, despite lifestyle modification, the body's set point still result in regaining unwanted fat and weight.

2. The Rewarding System
   The rewarding system in the nervous system of the brain influences and motivates a persons' eating habit. To perhaps eat more due to a previous 'pleasurable experience'. Hence, in obesity, the sight of delicious food may encourage one to consume the food more or repeatedly resulting in over-eating and weight gain.

Why should we consider medical management of weight loss?

Obesity is a condition when the body has excessive fat that can potentially compromise our health by increasing risk of chronic diseases.

Chronic uncontrolled obesity is associated with various health comorbidities such as cardiovascular complications including heart disease, stroke, type 2 diabetes mellitus, hypertension, fatty liver, gallstones, obstructive sleep apnoea, osteoarthritis, increase risk of organ cancers (such as breast, ovarian, thyroid, colon, liver, kidney, uterus cancers), mood disorders including depression.

In men,
Chronic obesity can be associated with lower testosterone, poor libido, erectile dysfunctional state, reduced sperm count and poorer sperm quality, affecting men's virility.

In women,
Long term obesity is known to be associated with infertility with infrequent ovulation, exacerbating concurrent menstrual disorders such as polycystic ovarian syndrome (PCOS). In pregnancy, excessive weight increases the risk of gestational diabetes, preeclampsia or even big baby (macrosomia)- which can be dangerous to both mother and unborn infant.

By managing excessive weight, one is taking charge of their general health and preventing the risk of developing above health morbidities.

What are the medications available in the pipeline for weight loss?

Glucagon-like peptide-1 receptor agonist also known as GLP-1 Receptor Agonist (GLP-1 RA) has been hitting the news headline for recent years. GLP-1 RA has been used for years, even now in the management of diabetes mellitus. It is now licensed and approved of this same drug to be used for weight loss safely and effectively.

GLP-1 RA acts as the body's natural proteins in facilitating the metabolism blood glucose and body's digestive system. GLP-1 RA increases body's production of insulin, slows down stomach emptying process and improves satiety feeling. As a result, following use of GLP-1 RA, one expects better glucose control of the body, feeling fuller, eating lesser and a result, a lighter body weight.

It is vital to speak to your doctor on your interest on these medications, and obtain GLP-1 RAs by your licensed prescribing physician and NOT obtain these medications from online unverified sources or over the counter due to potential counterfeits and the possible side effects of these medications. These medications will require close monitoring and regular follow up with your physician.

Who is suitable for medical management of weight loss?

Pharmacological treatment of obesity has been increasingly popular and clinically proven to be effective in achieving target weight loss.

It is imperative to note that pharmacological treatment of obesity is not a substitute against lifestyle behavioral changes and requires careful follow up with one's prescribing physician due to possible side effects from the medications.

Those with a 

• body-mass index (BMI) of 30 kg/m2 or more  OR 
• body-mass index (BMI) of 27 kg/m2 or more + presence of obesity related comorbidities 

can consider medical management for obesity.

Surgical intervention such as bariatric surgery can be offered to individuals with severe or morbid obesity with BMI > 32.5 kg/m2. As there is possible weight regain following bariatric surgery, sometimes your specialist may combine pharmacological treatment and surgical treatment in long term maintaining of ideal weight.

Why do we need to be supervised medically periodically when we are on weight loss medications?

Long term regular follow up with your trusted healthcare providers are needed when you are on weight loss medication. Follow up can be in the form of physical face-to-face review, telemedicine, depending on the comfort and arrangement between the attending physician and yourself. 

Medical supervision is required periodically in order to

• Ensure minimal or no side effects experience when taking medication for weight loss
• Ensuring no complication or side effects from losing weight itself
• Regular laboratory blood tests are required to monitor the effect of weight loss  medication of weight loss on our internal organs
• Ensure weight loss does not exacerbate existing medical conditions
• Screening and managing any other metabolic conditions that can be associated with obesity
• Ensure sufficient calories and nutrients are maintained during the process of weight loss
• Monitor the weight loss progress and achieve target weight in due course.

What is expected of a successful weight loss with medical management?

A weight loss of 5-10% can result in significantly lower health comorbidities. Healthy and safe weight loss rate is advised around 0.5-1 kg of weight loss per week.

Realistic and practical treatment goals while on weight loss medication includes short term and long term weight loss, prevention of weight re-gain, improvement of general health comorbidities and management of drug’s side effects. As the drug response and treatment goal vary individually, it is important to discuss with your weight loss prescriber on realistic goals and expectations to avoid poor drug compliance, treatment failure and weight re-gain.

What are the challenges of medical management of weight loss?

Behavioral and Environmental Factors

It is important to understand that while using medications to aid weight loss is useful, medical management is not a substitute against mindful lifestyle modifications. While on weight loss medications, one is advised for moderate eating habits and regular physical activities. In real world, this is easier said than done. One may find it difficult to curb overeating due to eating schedule, or social pressure or work obligations.

Medication Compliance

Often, patients become less compliant to various reasons. With the beginning of the hype of starting weight loss journey with medications and seeing the effects, one may overtime lose the motivation or has the misconception that their 'goal has been achieved' and hence can slack and revert to old habits. It is imperative to understand obesity is a chronic condition, stopping medications overtime will likely lead to weight gain.

Social media misbelief and misinformation

One may have the misconception that long term taking 'weight loss medications' can be harmful to the body, hence reluctant to be on the medication for long run. While weight loss medications do come with side effects and potential health risk, regular close monitoring of your health with your prescribing doctor can definitely prevent and minimize the potential health complications from the medication. Besides, health benefits following successful weight loss with weight loss medication outweighs the risk from weight loss medication itself. 

Cost of Medication

This is a key factor that dissuade many away from weight loss medication. Unfortunately, most insurance policy may not cover for weight loss medications. Cost counselling prior starting of weight loss medication and long term cost discussion with your physician/ healthcare center may be useful to ensure you don't run into finance constraint in the midst of your weight loss treatment. 

Medication Side effects, concurrent health conditions

One may have to stop weight loss medication or change to other types due to the side effect of the drugs or even unsuitability of the drugs due to underlying medical conditions. Open communications between yourself and your physician is important on any unusual symptoms that arise following weight loss medication. Your doctor is at best to guide you through and customize your weight loss treatment.

Final words…

Sustainable weight loss is achievable through a combination of long term lifestyle modifications and effective medical management.

Connect with DB Clinic

If you find that you are struggling with managing your weight, feel free to reach out to DB Clinic without hesitation for further enlightenment on medical weight loss. Contact us now!

References

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