PHOTO: Katarina Wolnik Vera
Text: Alejandra Misiolek
As we discussed in a previous post about treatments for obesity, this condition has both psychological and physiological causes and consequences, therefore it should be addressed on both level – from psychotherapy and from medicine.
In this post I am going to describe the medical possibiities for treatment of obesity as a complement to the psychological ones.
What is the current state of affairs in terms of treatment?
1. Treating obesity does not mean dieting to lose weight.
Very frequently, if you are obese and when you visit a medical doctor, you can hear: you should lose weight, as if losing weight were easy (reading between the lines: if you are obese, it is your fault).
When you search the internet for solutions, you can easily become a victim of miraculous and harmful restricting diets or drugs and supplements that can do magic. It is a very unethical business that plays on feelings of people with obesity – shame and guilt and a fantasy of “being normative”. There are many “experts” on nutrition, many of them being celebrities, coaches, pseudo dietitians and others who lost a lot of weight themselves. Even if a patient manages to lose weight, they can easily fall into the trap of the vicious cycle of restricting and bingeing and weight fluctuations that, in the long run, increase the body weight. These can lead to a development of eating disorders and/or depression.
The reasons why obesity is frequently not correctly treated is lack of understanding of the problem and lack of resources in the public health system. The treatment of obesity is a long process, and it is supposed to be done slowly but steadily. Moreover, it should be a personalized and multidisciplinary treatment based on the proper understanding of each person that suffers from it and in collaboration with the patient. The motivation and the active role in the process are crucial. It does not help to motivate someone if we shame them, blame them, or impose certain rules on them.
2. The treatment plan should include objectives according to the SMART rule, they should be:
- time bound.
The professionals who treat obesity should act according to the 5A rule:
- ask, try to understand the patient and their perspective, motivation, difficulties reasons.
- assess, why the patient´s body weight is high and what is the state of health.
- advise, instead of imposing.
- agree – it is crucial for the patient to agree with the treatment plan.
- assist and support the patient throughout the process which can be challenging.
3. The nutritious objective in treating obesity is not losing weight or dieting but rather changing the habits related to eating.
The process should be based on accompanying the patient in developing new and personalized strategies that are healthy and helpful. The goals must be realistic, sustainable and adapted to each person. An interview that helps us understand the current situation and design the treatment goals and strategies is a very important part of the treatment. Some psychoeducation related to eating might be necessary but frequently patients have the knowledge, and they are lacking the ability to implement the knowledge. Analyzing the difficulties and supporting the patient in implementing new habits is frequently more helpful that educating them.
- Physical activity as an important component.
The treatment should also focus on including movement. Why? Physical activity might be challenging for a person with high body weight, but it has to be adapted to the possibilities and interests of each person. If we want to maintain the motivation, the goal has to be realistic. Concentrating on improving stamina or efficiency can be a good alternative goal to losing kilos and changing the number on the scales, which can be especially triggering for a person with obesity or an eating disorder. The reason why moving the body is important is mainly to reduce the possible consequences on health of obesity but also to maintain the metabolism that tends to go slower if we restrict calories.
- Pharmacological treatment
What are the currents pharmacological options for treating obesity? Among the most popular ones (and tested to prove they are a safe option), we can differentiate:
Orlistat is a tetrahydrolipstatin, a substance derived from lipostatin (a potent, irreversible inhibitor of pancreatic lipase) that limits the action of the enzyme lipase. It affects the function of the enzyme and diminishes the metabolism of the lipids, reducing their absorption. As the lipids are excreted, one of the important side effects is diarrhea. In the long run it helps reduce the body weight by approx. 6% and reduces cholesterol levels.
Bupropion is an atypical antidepressant primarily used to treat major depressive disorder and to support smoking cessation. Bupropion acts as a norepinephrine–dopamine reuptake inhibitor and a nicotinic receptor antagonist. It is also popular as an add-on medication in the cases of “incomplete response” to the first-line selective serotonin reuptake inhibitor antidepressant.
It also has an effect on the hypothalamus by stimulating Pro-opiomelanocortin (POMC) and CART (Cocaine- and amphetamine-regulated transcript), thus augmenting satiety. It also increases the levels of beta endorphins, affecting also the reward system.
It is especially indicated if the cause of eating problems and obesity is emotional.
The side effects of bupropion can be headache, insomnia, dry mouth, nausea, and vomiting. Seizures and hypertension are an important contraindication to use this medication. It is also contraindicated in anorexia and bulimia and shouldn´t be used together with certain opioids like tramadol or codeine.
Liraglutide is an anti-diabetic medication used to treat type 2 diabetes, obesity, and chronic weight management. It is sold under the commercial name Saxenda and it is a glucagon-like peptide-1 receptor agonist (GLP-1 receptor agonist) also known as incretin mimetics. It works by increasing insulin release from the pancreas and decreases excessive glucagon release. It also affects the hypothalamus, inhibiting hunger and incrementing satiety.
It is given by injection under the skin.
Common side effects include low blood sugar, nausea, dizziness, abdominal pain, and pain at the site of injection. Gastrointestinal side-effects tend to be strongest at the beginning of treatment period and subside over time.
It should be used for at least 6 months and can be used long-term. The clinical studies show that patients tend to lose between 5 and 10% of their body mass after long-term use and their sugar levels reduce significantly.
The pharmacological support has certain possible side effects, and it shouldn’t be treated as a magic solution. It should ideally be accompanied by other forms of treatment to achieve long-term results.
However, in certain cases, it may offer an important boost for patients who suffer from severe complications of their metabolic state, who have attempted to lose weight on numerous occasions or who need help with motivation.
- Bariatric surgery.
Bariatric surgery is probably the last resort that should be offered to patients with obesity. It is an invasive option with numerous side effects and does not guarantee not putting on weight again. It should be done after a psychological evaluation and always in collaboration with a multidisciplinary team. There are temporary options and long-term options for reducing the stomach or the absorption surface of our bowels.
We can conclude that obesity is a multi-layered condition that can become both a medical and psychological problem, therefore requieres treatment by a multidisciplinary team of specialists. Patients should be treated with understanding and without shaming and the treatment programs should be individualized and adapted to the needs to each person.
Source: Obesitologia kliniczna. Magdalena Olszanecka-Glinanowicz. @-medica press, 2021.