New Year, old habits

Strategies for weight loss after the silly season.

WITH the festive season upon us, thoughts turn to eating and drinking. Then, usually about 10 am on New Year’s Day, these thoughts turn to weight loss.

Putting aside the question of whether this is a logical – or even sensible – approach, it may be helpful to look at what is available when patients start rolling in for their New Year ‘quick fix’ to lose those extra kilos.

There are a number of strategies for weight loss. Some are unsupported or have a limited evidence base, such as most over-the-counter products (they take more weight off the wallet than the body), ‘alternative’ techniques, commercial diet programs (they don’t publish their results, so are impossible to assess) and self-directed diets (although they may work for some people).

So, what is left? All approaches require a permanent lifestyle change to be successful. This involves changing energy intake and energy expenditure.

The key issue comes down to ‘volume’, where this refers to calories or kilojoules. As seen in Figure 1 below, volume in and volume out are each made up of three simple components (remember, this is for weight loss, and not necessarily fitness or other aspects of dietary health).

Thinking of this balance sheet, there are some successful evidence-based ways of achieving it.

1. Surgery

There is little doubt that bariatric surgery is the most successful long-term weight loss solution, with losses of up to 35% of starting weight. Lap banding has been a popular technique for some time, but other bypass procedures (e.g. Roux-en-Y) are now coming back into vogue because of their more rapid effects in restoring normal metabolism. The downsides are the cost, the intrusive nature of the approach, and the possible, although low, surgical risks.

2. Meal replacements

Although these have only achieved respectability in recent times, mainly due to improvements in food technology and their use under supervision, they have proven value, including improvement in diabetes symptoms. Unfortunately, their success has resulted in a plethora of ‘me too’ products, many of which don’t meet the guidelines established for this type of product. Only those with the right ingredients to reduce genuine hunger are likely to work.

3. Prescription medications

Phentermine (Duromine) and sibutramine (Reductil) are the only two available for weight loss in Australia. The former is indicated for short-term use, and by achieving relatively quick weight loss can increase motivation to continue with lifestyle changes. The latter appears to work best in those with a genuine biological hunger (not psychological appetite) problem. Despite regular promises, there is not much new on the horizon. The anti-epileptic medication topiramate is currently being investigated for use in weight loss.

4. Pre-prepared meals

These differ from meal replacements in that they are full, reduced-energy meals. Nutritionally balanced versions are available and are an option for some people. The main problem (particularly with big men) is that they tend to eat two or three meals at a sitting, thus defeating the purpose. Using these meals alongside some of the other approaches discussed can help overcome this.

5. Counselling

Psychologists are realising the role they have to play in obesity and weight control, some of which has a psychological basis (e.g. early childhood experiences such as physical and sexual abuse) or needs to be dealt with using behaviour modification or cognitive behavioural therapy principles. Good counselling can also involve the use of other techniques discussed here.

6. Exercise approaches

Although not as effective as a reduction in food intake in the early stages of weight loss (it’s always easier to take 1000 kcals out of a diet than add 1000 kcals of exercise – or the equivalent of walking about 15 km a day), exercise comes into its own during the maintenance phase after early weight loss. It also has significant benefits in glucose control, irrespective of weight loss.

While there is still no magic bullet for weight loss, modern treatments take a mix-and-match approach (see Figure 2, below).

Don’t regard any of this as one-off treatment. Like other lifestyle-based diseases, weight control is a lifelong process – at least in the modern ‘obesogenic’ environment.

Professor Garry Egger is Director of the Centre for Health Promotion and Research, Sydney, and professor of lifestyle medicine and applied health promotion at Southern Cross University, Lismore, NSW