Chapter 3
How Is Obesity Treated?

people use many methods to try to treat obesity by losing weight. Different techniques work best for different individuals, and in some cases an obese person must try a variety of strategies before finding one that helps. Sometimes nothing seems to work, and the person remains unable to either lose weight or keep it off, no matter what they try.

The National Heart, Lung, and Blood Institute stresses that any viable weight-loss program should focus on long-term goals. "Remember, quick weight loss methods don't provide lasting results. Weight loss methods that rely on diet aids like drinks, prepackaged foods, or diet pills don't work in the long run. Whether you lose weight on your own or with a group, remember that the most important changes are long-term."¹⁰ These long-term changes include making lifestyle adjustments that incorporate healthy eating and exercise into everyday life so that a healthy weight can be maintained over the long run.

Goals of Treatment

Whichever method of weight loss is used, the goals of treatment are similar. It once was that physicians and other experts who designed treatment programs tried to help an obese person achieve their ideal weight based on official height-weight charts. But most obese people could not achieve this goal, so experts gradually modified the goals of treatment. Today, most programs aim for what is known as the 10 percent solution—to lose about 10 percent of body weight as a method of reducing the complications of obesity. This focuses on managing weight in the context of overall health rather than setting a goal of attaining what is considered an ideal weight, though many obese individuals do end up choosing to lose more than the recommended 10 percent as a method of looking and feeling their best.

Doctors say that the best way to lose any amount of weight is slowly, at a rate of one to two pounds per week, to be safe. A gradual weight loss also helps keep the weight off permanently. Reducing caloric intake by five hundred calories per day generally results in a one pound per week weight loss.

Experts recommend keeping track of calories consumed and expended to help reliably achieve a gradual weight loss. This involves tabulating foods eaten and portion sizes in addition to calories expended in daily exercise and activities. The number of calories expended should exceed the number taken in so weight loss can occur. Charts listing the number of calories in certain foods are readily available from a variety of sources. In order to calculate the number of calories expended, the number of calories used in various activities must be added to the basal metabolic rate (BMR), a measurement of the number of calories needed to live while resting. BMR depends on age, body type, degree of obesity, the amount of thyroid hormone produced, body temperature, environmental temperature, and a host of other factors. There are several formulas available for calculating BMR based on height, weight, and age. To find out how much energy is expended during certain activities, doctors and exercise authorities have charts that detail these values. The number of calories expended during a particular activity varies slightly from person to person depending on body composition and effort put forth, so these values are not accurate to the letter, but they do offer a good idea of energy expenditure.

Methods of Losing Weight

Whether the emphasis is on counting calories, increasing exercise, or other factors, there are four basic types of treatment available for obesity: diet and nutritional counseling, behavior therapy, drugs, and surgery.

The most common, and the first line of treatment, is dieting. Although special diets for weight reduction were unusual until the nineteenth and twentieth centuries, they did exist before that time. One early example is the Greek physician Hippocrates recommending a diet high in fatty foods to feel full and so the body would grow tired of fat. Hippocrates also recommended that an obese person eat only once a day to help lose weight. Doctors now know that fatty foods do not necessarily make a person feel full, nor do they make the individual grow tired or fat. Eating once a day is also known to be unhealthy.

Another early diet plan was conceived in 1558 by the obese Luigi Cornaro of Italy, who put himself on a diet that included twelve ounces of food and fourteen ounces of liquid per day. Cornaro lost weight on this plan, his health improved, and he lived to be ninety-one years old. His book A Treatise of the Benefits of a Sober Life was one of the first diet books ever published.

The Scottish physician George Cheyne was another notable early diet book author. He wrote several books in the early 1700s about his experiences with different diets. Cheyne, who had shortness of breath, asthma, and stomach problems, tried various diets and medications to lose weight. He tried a milk diet and lost weight, but eventually gained it back. Finally, he followed a vegetarian diet that he consumed with milk, tea, and coffee and was able to keep the weight off and improve his health.

In the 1860s, William Banting of London popularized a diet consisting mostly of lean meat, dry toast, soft-boiled eggs, and green vegetables. He lost over fifty pounds, and his book Letter on Corpulence describing his diet became famous in England and America. His method of dieting became known as the "banting."

Modern Diets

After the early weight-loss diets, an entire dieting industry developed during the twentieth century, with every imaginable variety of solutions offered. Some diets stress high protein, others high carbohydrate or low fat. Some even suggest an all-liquid diet, and others offer a combination of approaches. While the best approach varies by individual, doctors say that any diet should provide adequate nutrition while involving intake of less food than the person's energy requirements. Ideally, an effective diet should be one that can be sustained long term to prevent medical problems and the yo-yo effect of weight loss and gain that so many dieters experience. That is why most experts caution against "fad" diets, which overemphasize one food or type of food, since they do not provide balanced nutrition. Such fad diets include the grapefruit diet, the cabbage soup diet, the no-carbohydrate diet, and so on.

The near-starvation or "crash" diets that some people attempt are also not recommended by most medical authorities. People who follow these types of diets may lose some weight but will probably gain it right back when they begin eating again. They also can experience serious health risks and even death if the diet is extreme. These crash or starvation diets limit calories severely to four hundred to eight hundred calories per day. They include liquid protein diets and various semifasting regimens like Optifast and Medifast. Doctors say these plans are so risky that they may require hospitalization so the diet can be conducted under direct medical supervision, if the person elects to follow the plan. The Food and Drug Administration warns, "Very low calorie diets are not without risk and should be pursued only under medical supervision. Unsupervised, very low calorie diets can deprive you of important nutrients and are potentially dangerous."¹¹

The lack of nutritional balance in these extreme diets can lead to chemical imbalances of elements like potassium, magnesium, and phosphorus, even if vitamin and mineral supplements are taken. Dizziness, fatigue, headache, muscle cramps, rashes, dry skin, bad breath, and gastrointestinal upsets are common side effects. Heart irregularities are responsible for many of the deaths attributed to these very-low-calorie diets.

Most experts recommend what are known as conventional, well-balanced diets for safe weight loss. These diets limit calories to between twelve hundred and two thousand calories per day. Some emphasize certain types of foods or combinations, and most require drinking lots of water.

Self-Help Groups

Many people who are dieting choose to attend one or more of any of a number of self-help groups that have been set up to prescribe diets and give support to people trying to lose weight. Examples are Weight Watchers, Take Off Pounds Sensibly (TOPS), and Overeaters Anonymous. Overeaters Anonymous is based on the principles of Alcoholics Anonymous. Such groups seek to provide support to those who have an addiction like alcohol, or, in the case of obesity, food. Other self-help groups tend to provide group sessions, counselors, meal plans, dietary education, and even specially packaged foods. Many people find they benefit from the social setting and shared experiences provided by such groups. People lose varying amounts of weight; some keep it off, especially if they continue to attend meetings that follow the program, while others quit and may gain back whatever weight they lose.

The National Heart, Lung, and Blood Institute recommends some guidelines for choosing one of these weight-loss programs. Questions to ask include finding out about the quality of the counselors, supervision by physicians or registered dieticians, availability of long-term counseling or a support system after the program ends, quality of the food choices, and whether or not the goals and rules are realistic. Prospective clients should also find out how many people successfully complete the program, their average weight loss, and fees for services and items like dietary supplements.

Why Diets May Not Work

Whether an obese person tries to lose weight using a self-help group diet plan, through a medically supervised diet, or simply on their own, the fact is that many times diets do not work for several reasons. One reason is that many people do not stick with the diet for long enough to make a difference. Another is that, in some people, the body is very efficient at trying to maintain a particular weight and level of fat. This level is called the set point. Some peoples' bodies work hard to maintain this set point. For example, in one experiment, a group of people who were consuming fewer calories than usual showed a 15 percent drop in energy expenditure. This meant that their bodies were burning fewer calories in response to taking in fewer calories. This made it nearly impossible for these individuals to lose weight by cutting calories and dieting alone.

Researchers, though, have found that it is possible to reset the set point. This can be achieved by changing the type of foods consumed—from rich, fatty foods to low-fat, low-sugar choices—and by increasing the level of physical activity. This is why most diet programs also include an exercise program. The best type of exercise for helping to lose weight requires the whole body to move, as in walking, jogging, or swimming. Experts emphasize the importance of incorporating such exercise into a daily routine, as well as making small lifestyle adjustments like climbing stairs instead of taking an elevator and parking farther away from a destination to get in more walking.

Behavior Modification Programs

Making changes like incorporating exercise and following a reduced-calorie diet are examples of behavior modification techniques designed to help obese people lose weight. Such changes can be part of a formal behavior modification program, which is the second major type of weight loss strategy, or may just be undertaken by an individual as part of an informal program in their quest to lose weight.

Formal behavior modification programs treat obesity as a learned disorder. Such programs seek to change an individual's behavior so they behave like a nonobese person. The idea is that this will facilitate weight loss. Often these programs are administered by psychologists who specialize in the treatment of eating disorders. Sometimes self-help groups like Weight Watchers incorporate these techniques into their weight-loss plans.

Some behavior modification programs teach patients to carefully monitor the number of calories they ingest. They may also involve teaching the person the behavior of eating very slowly or of eating only in a certain place in the house. Some programs prohibit eating in front of the television to prevent "mindless" eating. Some plans involve rewards, such as money, for people who successfully modify their behavior and lose weight, and some require a certain amount and type of exercise each day. In many cases, a therapist also counsels the individual to address issues of depression or anxiety that may underlie an eating disorder.

As with other weight-loss techniques, the success of behavior modification programs depends on a particular individual's motivation to succeed, on self-discipline, and on other factors, such as family support. Some obese people do very well in teaching themselves to change their behavior and lose weight, while others find that they are unable to make the necessary changes to succeed.

Diet Pills

The third main type of treatment for obesity involves weight-reduction drugs, or diet pills. These drugs include a variety of types, such as purgatives to empty the intestines, diuretics to promote water loss, emetics to promote vomiting, stimulants to suppress the appetite, and others. Most of these drugs have serious side effects and must be used carefully. Amphetamines, for example, the major kind of stimulant used to suppress the appetite, often cause sleeplessness, increased heart rate and blood pressure, dizziness, tremors, headache, impotence, and hallucinations. These drugs also lose their effectiveness over time, so larger and larger doses may be required to keep promoting weight loss. They can also be psychologically and physically addictive. In some states, it is illegal for physicians to prescribe amphetamines for weight loss.

A newer group of drugs that are similar to amphetamines include Adipex, Bontril, Fastin, Prelu-2, and Tenuate. They are somewhat safer and have fewer side effects, but can still be dangerous. Most manufacturers recommend only short-term use of these drugs. Another newer drug is the well-known fenfluramine-phentermine combination (fen-phen), banned from the market in 1997 after many patients developed heart-valve damage and high blood pressure. Some patients even died while taking the drug. Fenfluramine itself was also banned, but the appetite suppressant phentermine is still on the market, since it does not appear to be dangerous when used by itself.

One of the newest prescription weight-loss drugs is sibutramine, marketed as Meridia. It works by making the user feel full and also increases the metabolism. It has adverse side effects, including raising blood pressure and heart rate, so it cannot be used by people with high blood pressure or heart problems. Another popular new drug is orlistate, marketed as Xenical. It works by blocking about 30 percent of dietary fat from being absorbed by the intestines. Sometimes this causes gastrointestinal upsets because this fat is passing through the body undigested.

Besides the prescription options, there are many weight-loss dietary supplements sold in drugstores and health-food stores and available without a prescription. These substances are not regulated by the Food and Drug Administration in the same manner as are drugs, so many people consume them thinking they are harmless. But experts point out that some of these supplements are far from harmless. For example, the American Heart Association has urged the federal government to ban the sale of ephedra, an herbal supplement often used as a weight-loss aid. Ephedra produces high blood pressure, irregular heartbeat, stroke, heart attack, and even death in some cases. After the February 2003 death of Baltimore Orioles pitcher Steve Bechler from ephedra, the Food and Drug Administration proposed the first manufacturing standards for dietary supplements, but they had not banned the substance as of October 2003.

Treatment with Surgery

For many obese people, weight-loss drugs, behavior therapy, and diets are ineffective in helping them lose weight. When this happens and there are serious health complications from the obesity, the only other option may be surgery. Surgery to treat morbid obesity is known as bariatric surgery. Doctors who perform such operations emphasize that they are not cosmetic procedures, but instead may be medically necessary to control the many health problems that often go along with severe obesity.

As Norman Ackerman, a bariatric surgeon, explains in his book Fat No More, surgeons used to be involved with treating only the effects of obesity rather than the obesity itself.

Surgeons have been involved with the care of very obese patients for many years. At first, our task was to treat some of the complications of obesity. Neurosurgeons and orthopedic surgeons have treated the various back problems that plague the very obese, and orthopedists have repaired, and more recently, replaced diseased joints in the legs of these unfortunate patients. Cardiac surgeons have been operating on the hearts of obese and other patients for about forty years.¹²

Early Surgeries

In the 1950s, surgeons began to experiment with operations to treat obesity itself rather than just its effects. In 1954, Arnold Kremen and John Linner at the University of Minnesota in Minneapolis published an account of their studies on removing part of the small intestine in an obese woman to help her lose weight. The operation, known as a jejunoileal bypass or intestinal bypass, removed a section of the jejunum (the upper small intestine) and the ileum (the lower small intestine). The surgeons removed about 75 percent of the small intestine and the woman lost over thirty pounds. Later they removed more and she lost an additional seventy pounds.

Other surgeons began performing similar operations to help morbidly obese people lose weight. Some bypassed the entire ileum and connected the jejunum directly to the colon (the large intestine). Others bypassed part of the small intestine and some of the large intestine. But there were severe complications when the colon was bypassed, including nutritional deficiencies, diarrhea, and liver failure, so the so-called jejunocolic bypass was not performed for very long. The jejunoileal bypass became the most popular operation for weight loss in the 1960s and 1970s. Different surgeons believed different lengths of the jejunum and ileum should be removed to achieve the best results. The operation worked because it allowed only a fraction of the calories consumed to be absorbed by the body. Patients often experienced complications like diarrhea, poor absorption of some nutrients, liver damage, kidney stones, and nausea and vomiting, but the surgery did help many severely obese people lose weight. When the gastric bypass was invented, however, the intestinal bypass became obsolete.

The Gastric Bypass

The gastric bypass operation, also known as stomach stapling, has become the most common surgical procedure for treating obesity. It is done using stainless steel staples, stitches, or plastic or metal bands to make the part of the stomach that receives food very small so the patient will eat less. It also makes the outlet from the stomach small so that food leaves the stomach slowly and the person feels full for longer. The food goes directly from the upper part of the stomach to the intestine through an opening. The lower part of the stomach is bypassed; this is where the name gastric bypass comes from.

There are some variations on the gastric bypass. Sometimes the upper part of the stomach is made to empty into the lower stomach, so this area is not bypassed; the procedure is called a gastroplasty. Results are similar to those of the gastric bypass.

After a gastric bypass or similar operation, the patient cannot eat or drink for four or five days. Then they are allowed a liquid diet, progressing after several weeks to a normal diet. But because of the reduced size of the stomach, they can only tolerate a very small amount of food at a time. Because of this, the person loses substantial amounts of weight. One obese woman who had a gastric bypass went from 250 pounds to 122 pounds in one year; an obese man went from 497 pounds to 232 pounds. Sometimes the weight loss is so great that plastic surgery is required to tighten up the resulting loose skin.

Even though this operation leads to substantial weight loss in many people, there are still risks and complications. One problem sometimes seen is injury to the spleen, which lies next to the stomach. Other complications may include excess bleeding, pneumonia or blood clots in the lungs after surgery, infection, vomiting, ulcers, gallstones, vitamin deficiencies, and anemia. But for the severely obese people who undergo the operation, most say the risks are worth it because it is their last resort for losing weight after other methods have failed.

Other Surgery

There is one other surgical technique often used to treat severe obesity. With jaw wiring, an oral surgeon wires the jaw shut so the patient can take in only a liquid diet through a straw. The diet usually consists of milk, fruit juice, vitamins, and sometimes liquefied soft foods.

Although patients may lose weight, the procedure has its drawbacks. Some patients complain of dry lips, sore gums, and bad breath. Also, if the patient has to vomit, they risk choking because the mouth will not open. For this reason, many doctors give these patients a set of wire cutters to use in such an emergency.

Generally the jaws remain wired shut for about six months. While most people lose significant amounts of weight, once the wires are removed, many people resume their old eating habits and begin to regain the weight they lost.

Alternative Treatment Methods

Besides the four major types of treatment for obesity, there are several alternative methods. One is spa and water cures, which have been used since as far back as the Roman Empire. These include various types of hot and cold baths and saunas. The hot baths and saunas are supposed to exert their therapeutic effects by making the person sweat off some weight, and other forms of water treatments are supposed to be healthy in general but not specifically beneficial for weight loss. While experts say that these treatments that cause sweating may result in the loss of a few pounds, most agree that water treatments are not effective for permanent or major weight loss.

Hypnotism is another alternative treatment. Here, a professional therapist hypnotizes the obese person and leaves them with the suggestion that they will be able to reduce the amount they eat when they wake up. Most people who try this method report that it is not successful in treating obesity, though there are many professional hypnotists who claim that it works.

Acupuncture, an ancient Chinese system of medicine that uses fine needles inserted at various critical points on the skin, has also been used to help with weight-reduction efforts. An acupuncturist places needles in appropriate locations to relieve hunger and suppress the appetite. Sometimes a staplelike device is placed on certain points in the outer ear and left there to accomplish the same purpose. Many patients say the technique works well, though there is little scientific data on whether acupuncture treatments effectively reduce obesity. One recent scientific study did show that patients who received acupuncture treatments to the ear had significantly more appetite reduction and weight loss than did control subjects on the same diet and exercise plan. This led the researchers to conclude that "ear acupuncture at designated points, in conjunction with a reduced calorie diet and increased physical activity, is effective in treating obesity."¹³

Maintaining Weight Loss

Whichever methods people use to lose weight, once the desired weight loss is achieved, doctors recommend a variety of techniques for best keeping the weight off, since regaining lost weight is a common problem for the obese. Strategies include limiting intake of fast foods, eating several small meals each day instead of two or three large ones, restricting intake of fats and sugars, maintaining a regular exercise program, and taking weight measurements regularly. Keeping a food diary can also help. Many people also find that keeping fresh, low-fat foods readily available is important. So is planning what to eat in advance rather than grabbing whatever sounds good at the moment. Drinking plenty of water throughout the day also helps keep the appetite in check.

In one study of people who managed to lose sixty or more pounds and keep it off for an average of six years, the important factors seemed to be eating a low-fat diet, weighing frequently, being physically active, and eating breakfast every day.