Weight loss: what are your options?

by Dr. Jacki Hart

Weight loss is a very broad topic and my intention is not to exhaust the subject, but to give a sense of a few of the current issues and dilemmas, especially regarding the use of medications and supplements, and, as always in this column, describe where traditional and alternative approaches may interface.

The prevalence of obesity has increased steadily in Western cultures over the past century, particularly during the last several decades. In fact, some researchers say that the prevalence of overweight and obesity has grown to epidemic proportions. In the United States, most sources report that 33%, or 1 out of every 3 Americans, is considered overweight; a few sources actually report that number as closer to 50% or more.

Being overweight is closely linked to many very serious health conditions, most particularly risk factors for heart disease and stroke, including high blood pressure, high cholesterol, high triglycerides, low levels of HDL (high-density lipoprotein -- the "good" cholesterol), and adult-onset or "type 2" diabetes. Fortunately, even modest reductions in weight can help improve these conditions. Plus, practicing the behavioral changes of a more healthful diet and regular exercise can actually reduce these risk factors whether weight loss occurs or not.

Scientists often explain weight loss quite simply in terms of the "energy balance equation": energy in versus energy out. To lose weight, you must consume fewer calories than you burn or, in reverse, you must burn more calories than you consume.

This is, of course, easier said than done. But no matter what weight loss methods you may employ in addition to diet and exercise medication, supplements, surgery, therapy, group support, etc. the principle of energy balance is unavoidable. In fact, experts from both traditional and nontraditional disciplines agree that to achieve and maintain weight loss you must make changes in your diet and activity level to favorably affect the balance of the energy equation.

Getting started is often the most difficult part of losing weight. Any changes you make in your eating and exercising behaviors must become habitual, which takes time. In addition, carrying extra weight, no matter how much, can affect how you feel about yourself psychologically, sometimes making it more difficult to take the necessary steps to begin to change.

The following five strategies are crucial to successful weight loss and can help to overcome some of these barriers:

• Set realistic goals and monitor your progress toward achieving these goals.
• Modify your eating and exercise behaviors as well as habits influencing both.
• Examine and restructure unrealistic, negative thoughts or expectations.
• Reduce stress.
• Develop a network of social support.

These strategies bridge the gap between traditional and alternative medicine and have been used successfully by people engaged in many different approaches to weight loss.

There is a great deal of interest in whether prescription medications or supplements can facilitate weight loss. Interestingly, many of the currently available medications and supplements work in similar ways (see table). (Note: the drugs and ingredients listed do not constitute a complete list of all weight loss agents available, but do represent some of the ones more commonly used).

• Mechanism of action
• Prescription medication
• Dietary supplement ingredient
• appetite suppression
• sibutramine (Meridia)
• chromium picolinate

gymnema

• improved energy expenditure (burning of calories)
• sibutramine (Meridia)
• chromium picolinate

gymnema

• blocked absorption of dietary fat
• orlistat (Xenical)
• chitosan

Studies have shown that some medications, such as sibutramine (trade name Meridia) and orlistat (trade name Xenical), facilitate weight loss and maintenance of that loss for up to two years when they are used as adjuncts to diet and exercise. These types of medications are usually prescribed only for severely obese individuals for whom other methods of weight loss have not worked. Accordingly, these medications are not without side effects or potential adverse events and should only be used with careful monitoring by a medical doctor and a registered dietitian. I would make the same case for dietary supplements that people taking them be supervised and monitored by health professionals. It is also important to point out that medications cannot be used indefinitely because the long-term risks are not known.

Although supplements do not undergo the same rigorous approval process as drugs, it is possible, even likely, that some of the same benefits, and therefore principles of use, are applicable to weight loss supplements, since many have the same mechanisms of action as drugs. Similarly, some of the same risks and side effects may be present as well.

The question is: At what point should you consider taking medications or supplements

Its clear that although the "energy balance" principle behind weight loss may be simple, actually losing weight is not. Lifestyle changes in diet and exercise are imperative to successful weight loss, but trying a prescription medication or dietary supplement might also be an option to consider, depending on your weight and your health status.

My opinion is that either a medication or a supplement can be a useful adjunct to diet and exercise when used under the supervision of a doctor or qualified practitioner. I would add the following suggestions:

• Medications and supplements are not substitutes for behavioral changes, which are crucial to maintaining weight loss over the long term.
• Medications and supplements should be used only by people who are significantly overweight and when more standard methods have been unsuccessful.
• Medications and supplements should be used for a limited period of time to be decided upon in conjunction with the healthcare professional, but, in my opinion, absolutely no longer than one year.
• Try to have realistic ideas about what the medications or supplements will help you accomplish.
• Explore the deeper individual and cultural issues you may have about food, eating, and body image, with guidance from a professional. In doing so, use this information not for self-judgement but for greater self-understanding, acceptance and compassion.
• Remember that even modest changes can make a big difference.