Brisbane Weight loss clinic - medication, VLED, diet & surgery

Why do I find it difficult to lose weight?

Hey, this is normal! Let’s start with some truths.

  • Obesity is not a lifestyle choice. Sure, we need to accountable for our choices but no one chooses to be obese. We are surrounded by high calories choices.  Just  look at the specials at the supermarkets – with discounts for purchasing large quantities, & discounts for the less helpful food often being at the end of the aisles. Obesity is a battle where the two sides are the brain-gut interface, and the Obesogenic environment.
  • More and more is being understood about how “gut hormones” play a key role with hunger regulation and other physiological changes.  These hormones act like a thermostat and are partly genetically pre-programmed. Our genes have evolved to prevent weight loss, not to prevent weight gain.
  • Another important physiological variable is the basal metabolic rate. The Basal metabolic rate goes up and down according to intake of calories. The body also “remembers” what its Basal metabolic rate “should be.” This memory may even start in the uterus. The memory helps explain why a diet may work the first time but not the second.
  • The environment is also much less active than in the past – with cars and carparks adjacent to our work, lifts, technological gadgets & so on.

OK, so obesity is not the result of a lack of willpower. Let’s get to the science.

Not long ago it used to be thought that fat cells were for storage of energy. It is now known that fat cells are hormonally active. Fat cells send signals to the brain and body to help regulate appetite and energy levels.

Genes play an important role in a whole host of different factors – our metabolic rate, how much we fidget, how much energy we use to control our posture, and how we respond to different diets.

There are important psychological issues that affect us all:

    •  We all tend to make the same choices we’ve made in the past: the so-called status quo bias. It takes a prolonged mental effort to make actively & consistently different choices than we’ve made in the past.
    • We tend to make choices that sort out the current situation (relieve of hunger) than help the long term issues (waistline).

Lon term weight loss is possible. It helps, though, to be aware of the multiple factors that make sustained weight loss so challenging – so that you can develop helpful long term strategies and make informed choices.

The end result is that weight is like an elastic band. Efforts to reduce weight are often very difficult to maintain over time so that the weight springs back up (again).

How much weight should I lose?weight loss goal

Try to set yourself a realistic goal eg. a gradual 5 to 10% weight loss.

You should:

    • Aim for sustained weight loss. The health benefits of a 5 to 10% loss of weight are considerable.
    • Set a realistic goal eg. 5 to 10% weight loss.
    • Lose weight at a maximum of 0.5 to 1Kg per week (go slowly!)
    • Aim for long term health benefits

Some people are motivated by a target to lose a much greater amount of weight than 5% to 10%! However, it’s fair to say that most (but not all) do not find those sorts of targets achievable in the long term – but go for it if that works for you!

What non-medical options are there?

Most people looking at this will have tried to lose weight many times – perhaps going from one diet to another their whole life. There will be some success stories. In terms of non-medical options, the occasional person reports losing and sustaining very significant weight loss with a particular type of diet, but those experiences are not reproducible. In other words, what works for one person may not work for another.

It’s important for people to feel supported in their attempts to lose weight through physical activity and dietary changes. There are a variety of ways of accessing help. Government funded programs come and go – your doctor will know what is or is not available in your area.

The main non-medical options (which may be combined) include:

  • Regular physical activity – of course very important but probably not enough
  • Diets – lots will make promises, research doesn’t come down heavily on one being better than another. Consider, however, the proven health benefits from eating a Mediterranean-type diet. The very low energy diet is a medical option & described later on.

The Australia Government website “Measure up” has some useful tips on how to get some weight off!

It’s important for people to feel supported in their attempts to lose weight through physical activity and dietary changes.

Any dietary tips for weight loss?

Evidence from scientific studies support the following:

    • Look at portions & proportions. Some people prefer to leave their plate empty even if they are already full. Consider increasing the proportion of vegetables relative to grain & protein foods.
    • Cut out Sugary Drinks – evidence from three trials shows that this change results significant weight loss.
    • Be aware that fruit drinks usually contain a high amount of calories.
    • Drink 500mls of water half an hour before a meal has been proven to help with weight loss.³

What are the medical options for weight loss?

Medical options for weight loss are growing and a GP with an interest in obesity management will be in a good position to discuss or take you through a medical weight loss program.

The most intensive medical options are:

    • Very low Energy Diet (VLED)
    • Medication
    • Bariatric Surgery
VLED

VLED

What is a Very Low Energy Diet?

A Very low energy diet (VLED) is a diet with less than 800 kCal per day. Optifast is the best known in Australia and is provided in a “kit form” – as shakes and soups for example. The first phase lasts up to 12 weeks and typically includes 3 meal replacements per day, at least 2 low-starch vegetables, 1 tablespoon of oil, and 2L of water.

A VLED works because it induces a state of “ketosis” that in itself reduces appetite. After a few days, the chances are you won’t feel hungry although there may be side effects such as fatigue, dizziness & menstrual disturbances.

Evidence shows that a VLED leads to a substantial weight loss when supported & monitored by both The GP & dietician.

The big advantage of a VLED compared to a normal ‘diet’ is that the ketosis suppresses appetite. Why? Because ketosis causes an increase in cholecystokinin which is a natural appetite suppressant. Ketosis also suppresses the hunger-hormone ‘ghrelin.’ In effect, ketosis is your friend.

The clinic has its own VLED recipe which is not quite as intense as the 100% VLED whilst still being effective.

Benefits of a VLED

  • Research shows an average 20% weight loss after 3 months when you are properly supported & monitored.
  • Lowers Blood Pressure
  • Improves control of Type 2 diabetes
  • Lowers Cholesterol

Monitoring a VLED

Side effects may include: Fatigue, dizziness, postural Blood Pressure drop, feeling cold, changes in bowel habit, muscle cramps, dry skin, rashes, hair loss. Changes to menstrual cycle. Tireness is understandably the most common side effect.

More severe & less common reactions:

  • Electrolyte disturbances (sodium and Potassium)
  • Abnormal liver function tests.
  • Gout
  • Gallstones
  • Lower bone mineral density

A Very low energy diet (VLED) is not suitable during pregnancy, breast feeding, adolescence, age over 65, recent heart attack &  some rare medical conditions such as porphyria. Also avoid with alcohol or drug abuse. May not be suitable in people with specific psychological problems.

The doctor will check your medical history, perform an appropriate physicam exam including your Blood Pressure, and arrange an ECG & Urine Test when appropriate. Guidelines suggest baseline blood tests that are repeated should the diet continue at 3 months.

Weight loss medicationWhat medication is available to help weight loss?

Specific medical treatments may supplement lifestyle attempts to loose weight and there are a range of options.

Orlistat (Xenical®). This inhibits the protein that helps to absorb fat in the gut. Dietary fat in the gut is therefore not completely broken down – and so remains in the bowel – and ends up in bowel motions. So the classic side effects are oily spotting of the bowel motions, flatulence, loose stools – these are most noticeable after a fatty meal. The evidence points to a weight loss of around 3Kg weight loss at 1 year’s treatment.

Phentermine (duromine®): This increases the available dopamine in the nervous system and therefore the side effects may include symptoms such as palpitations, headache, and may also increase the blood pressure that will need monitoring. The main downside, though, is that the medication is only licensed for 3 months use. The evidence points towards a weight loss immediately following treatment of around 3.5Kg.

Metformin. This medication has been around a long time to treat type 2 diabetes and more recently polcystic ovarian syndrome (PCOS).  A study of women with infertility & obesity showed a loss of BMI of 0.68 after 6 months metformin, and another study of women with obesity on anti-psychotic medication² found a weight loss of 4.8% after 3 months. Metformin is not approved to treat obesity on its own.

Liraglutide (Saxenda®) was introduced in Australia in 2016. The cost is a big factor for most people at around $387 per month. Saxenda is given by a self-administered daily injection. The results from the clinical trials look encouraging with 1 out of 3 people losing over 10% of their body weight.

Topiramate is not licensed for weight loss but is another option for prescribing by a doctor experienced in the management of weight loss. Side Effects are dose-related. Topiramate may be combined with Phentermine with appropriate medical supervision.

Lorcaserin is available in the USA but not in Autralia yet, and is a specific anti-obesity medication that results in a 3.2Kg average weight loss.

What about Bariatric Surgery?

Bariatric surgery often results in sustained significant weight loss. There are over 5 Bariatric Surgeons in Brisbane. Out-of-Pocket costs of a gastric sleeve after insurance varies significantly. Typically, the out-of-pocket cost is around the $2500 to $3500 mark in Brisbane though there are some services a little further away that get this down to around the $1500 mark.

The barrier to bariatric surgery are:

  • Concerns over side effects
  • Cost. Some medical insurance companies do not cover bariatric surgery but plenty do – including the option to be covered immediately on joining (ask!).
  • Perhaps a feeling that obesity can be “beaten” without surgery – maybe it can & certainly other options should be pursued.

Weight loss statistics (in general) are not encouraging. A recent 10 year follow up study of nearly 280,000 people showed “The annual chance of obese patients achieving five per cent weight loss was 1 in 12 for men and 1 in 10 for women. For those people who achieved five per cent weight loss, 53 per cent regained this weight within two years and 78 percent had regained the weight within five years.” However, within these figures some people do manage to maintain weight loss.

There has been quite a lot of publicity over side effects of bariatric surgery. When considering risks, bear in mind also the risk of ongoing severe obesity. The risks of ongoing obesity are usually the back of people’s minds when bariatic surgery is suggested.

The UK NICE guideline on bariatric surgery were updated in 2014 to suggest bariatric surgery be considered for people with

  • BMI 40 or more
  • BMI 35 or more with type 2 diabetes or high blood pressure or other significant conditions

Consider this: The NICE guidelines are funded by the UK government to advice on what the publicly funded national health service should fund in the UK – at a time of major resource limitations. The NICE guidelines suggest bariatric surgery at these thresholds because they have assessed the scientific facts: The risk of ongoing moderate to severe obesity generally outweighs the risk of surgery. This message may be lost at times because the risks of obesity is not something that is “out there” as much as it should be – perhaps because of the sensitivities involved. Follow this health.gov.au link to read about the risks of obesity.

Without surgery, around 90% of people with obesity eventually regain the weight they’ve lost. The author of this blog is a strong advocate of weight loss surgery.

The risk of ongoing moderate to severe obesity generally outweighs the risk of surgery

What are the health benefits of weight loss?

The health benefits in terms of reducing or controlling diabetes and reducing cardiovascular risks, high Blood pressure & Sleep Apnoea are very well known. Weight Loss also helps Polycystic Ovarian Syndrome and improves fertility rates following IVF.

The cancer risks of obesity are perhaps less well known. The lancet recently published a study into the effects of obesity on 22 different cancer and found that obesity is linked to 17 of them – some of the links are known to be very strong associations.