A person's motivation, commitment, and compliance are critical for long-term weight loss success - certainly, knowing that weight loss can reduce blood pressure, cholesterol, blood sugar levels, and many other obesity-associated health risks can be very motivating! The goals of treatment are first to prevent further weight gain, and then to reduce body weight and maintain the lower body weight over the long-term. A number of factors play a role in deciding about the most appropriate treatment of obesity including a person's BMI, waist circumference, associated health conditions, and their motivation to lose weight.
- Body weight alone can be used to follow weight loss, and to determine the effectiveness of a weight loss treatment.
- The initial goal of weight loss therapy should be to reduce body weight by about 10 percent from baseline over 6 to 12 months.
- To lose weight, you must use more energy than you take in.
- To improve long-term success, lose weight gradually (1-2 pounds/week).
- Long-term behavior modification therapy is necessary for long-term weight loss.
- If unable to lose weight, prevent further weight gain by exploring your barriers to weight reduction.
Treatment generally begins with lower calorie and lower fat meals, increasing physical activity, and incorporating behavioral modification techniques like engaging social support, using stimulus control, and stress management. Medications or surgical management require physician supervision. Before beginning a weight loss program, you should consult with your health care provider to know which of these treatments is right for you. Do make sure your provider is aware if you suffer from chest pains, dizziness or fainting, or if you plan a vigorous program and are over age 40 (men) or 50 (women).
Reduced Calorie Diet and Exercise
Treatment starts with a combination of a reduced calorie diet and increased physical activity. Cutting back intake by 500-1000 kcal daily can lead to a 26 to 55 pound weight loss in 6 months, with an average loss of around 26-35 pounds. A difference of one 12-oz. soda (150 calories) or 30 minutes of brisk walking most days can add or subtract approximately 10 pounds to your weight each year. Reducing your calorie intake by 150 calories a day, along with participating in moderate activity, could double your weight loss and is equivalent to approximately 20 pounds in 1 year. Fad diets and very-low calorie diets can result in substantial weight loss rapidly; however, the sustainability of these diets and their long-term benefits and health consequences are not well documented. Consult with your physician for the diet that's right for you.
Activities at the length of time specified from the following table will burn approximately 150 calories:
|Examples of moderate-vigorous physical activity|
Washing and waxing a car for 45-60 minutes
Washing windows or floors for 45-60 minutes
Gardening for 30-45 minutes
Wheeling self in wheelchair 30-40 minutes
Pushing a stroller 1½ miles in 30 minutes
Raking leaves for 30 minutes
Walking 2 miles in 30 minutes (15min/mile)
Shoveling snow for 15 minutes
Walking stairs for 15 minutes
Playing volleyball for 45-60 minutes
Playing touch football for 45 minutes
Walking 1¾ miles in 35 minutes (20min/mile)
Basketball (shooting baskets) 30 minutes
Bicycling 5 miles in 30 minutes
Dancing fast (social) for 30 minutes
Water aerobics for 30 minutes
Swimming laps for 20 minutes
Basketball (playing game) for 15-20 minutes
Bicycling 4 miles in 15 minutes
Jumping rope for 15 minutes
Running 1½ miles in 15 min. (10min/mile)
Less Vigorous, More Time
More Vigorous, Less Time
The importance of behavior modification cannot be stressed enough. Unless you change the way you think about food and exercise habits, weight loss is unlikely to be maintained over the long-term. Behavioral strategies to reinforce changes in diet and physical activity can produce a weight loss in the range of 10 percent of baseline weight over 4-12 months. Behavioral strategies include stress management, social support, recording food and calorie intake, and modifying environmental cues that are associated with overeating and inactivity. Commercial weight loss programs that promote these behavioral changes may be useful.
When a reduced calorie diet, increased physical activity, and behavior modification are unsuccessful in creating significant sustained weight loss, medications may be helpful in selected patients. Medications may be considered in patients with a BMI of ≥ 30 or in those with a BMI of ≥ 27.5 with concomitant risk factors (e.g., smoking) or obesity-related illnesses (e.g. diabetes, heart disease). At present, two medications are approved by the United States Food and Drug Administration for long-term use as weight loss aids: Sibutramine and Orlistat. A lower dose form of orlistat is available over-the-counter (Alli). Both orlistat and sibutramine are most effective when taken in conjunction with a low fat/low calorie diet, regular exercise and behavior therapy. There is no convincing evidence to support the use of the so-called "fat burners" that are commonly advertised.
At present, five medications are FDA approved for long-term treatment of obesity: Liraglutide (Saxenda), Naltrezone/Bupropion (Contrave), Orlistat (Xenical, or Alli), and Phentermine/topiramate (Qsymia), and semaglutide (Wegovy). Each of them have unique mechanisms of action and some can be used for dual purposes (i.e. liraglutide can be used for diabetes).
Weight loss surgery is currently the most effective treatment for morbid obesity and the only effective approach for the extremely obese. Weight loss surgery may be an option in carefully selected patients with a BMI of ≥ 40 without obesity-associated health problems and ≥ 35 in those with obesity-associated health problems. Weight loss surgery should be reserved for patients in whom medical efforts have failed and who are suffering the complications of extreme obesity. Currently, the most common surgeries performed are gastric banding and the Roux-en-Y gastric bypass. Laparoscopic adjustable gastric banding (LAGB) restricts the entrance of food into the lower part of the stomach by placing a tight, adjustable prosthetic band around the entrance to the stomach. The Roux-en-Y gastric bypass (RYGB) both restricts the amount of food comfortably ingested by dividing the stomach and creating a small gastric pouch, and reconfigures the anatomy of the upper small intestine, thereby creating some degree of malabsorption. The RYGB is a much more technically complex operation but can also be performed laparoscopically.
These procedures normally result in sustained weight loss between 15% and 40% of total body weight, with a maximum weight loss about 12 months after the operation. The RYGB is more effective than the LAGB at causing sustained weight loss. Importantly, some individuals gain back weight in the long-term, emphasizing the point that the results from these surgical procedures are most effective when combined with a low fat/low calorie diet, regular exercise and behavior modification. An experienced surgeon and participation in an after-care program are recommended to optimize the chance for optimal results. It is also important to recognize that complications and mortality following surgical treatment of severe obesity do occur and vary based upon the procedure performed.
Currently, the most common surgeries performed for weight loss are Sleeve gastrectomy and Rou-en-Y gastric bypass (RYGB). The sleeve gastrectomy restricts the amount of food that can be ingested by removing part of the stomach. There are also hormonal effects (on ghrelin, the “hunger hormone”) that contribute to the weight loss. The RYGB restricts the amount of food comfortably ingested by dividing the stomach and creating a small gastric pouch but also bypass the first part of the intestine responsible for absorbing food, which leads to further weight loss. Both procedures are often performed with minimally invasive laparoscopic equipment.