weighty matters

Why the Conversation About Obesity Needs to Change

Photo: Digital Vision./Getty Images

When you lose weight, your body not only needs fewer calories to begin with, because it’s smaller, but there’s also a survival response that makes maintaining your new number extra hard: Your metabolism slows down and your hunger hormones go up. Your body fights to get you back to where you were, even if it’s not a weight that would be considered healthy.

Experts in weight management know about these bummer metabolic adaptations and tell their patients about them upfront, says W. Scott Butsch, an instructor of medicine at Harvard Medical School and a physician at the Weight Center at Massachusetts General Hospital. But the public doesn’t often hear this message, and the lack of knowledge does no favors for the perception of obesity, and obese people.

Not being able to maintain weight loss shouldn’t be viewed as a personal failing. It’s just an unfortunate fact of physiology.

“There’s this strange dichotomy wherein somebody who is overweight and has trouble keeping off 30 pounds to get off their anti-hypertensive medication is deemed lacking willpower, lazy, slothful, and gluttonous, whereas a person who is lean and can’t keep off five pounds to get into last summer’s bathing suit can get away with saying, ‘Well, I just have a slow metabolism,’” says Michael Rosenbaum, an obesity researcher and professor of pediatrics and medicine at Columbia University Medical Center. “Understanding of this phenomenon, that this is a biological problem, really should attenuate some of this self-loathing that people feel when they can’t keep weight off.”

Dr. Butsch says that educating people about these facts is essential. “We know that that can actually change weight stigma.” And this could help with treatment options as well as public perception.

Some experts in the obesity field are turning their attention to developing drugs for weight maintenance, including ones that mimic the effects of the satiety hormone leptin that drops after weight loss, or undo the muscle efficiency that leads to fewer calories burned — basically, medicines that reverse the adaptations that occur after someone loses weight.

Holly Lofton, an assistant professor of medicine and the director of the medical-weight-management program at NYU Langone Medical Center, says she recommends that some of her patients use the drug Liraglutide, which stimulates another satiety hormone that gets low after people lose weight. It’s been available for about a year and helps slow stomach-emptying. Still, some patients view this as “caving.”

“Too many times I see patients in my office with this shame and guilt. Even when they’re losing weight under my close medical care, they are reluctant to consider options that we have available such as medications and specialized diets or even surgery, because, they say, ‘I want to do it on my own,’” she says.

Surgery is often more successful than traditional diet and exercise. For some reason, the hunger hormones shift the opposite way after bariatric surgery, says Dr. Butsch. Following gastric bypass specifically, leptin goes up and hunger goes down. Doctors are still trying to figure out exactly why this happens, but they do know that gut bacteria can change following the surgery, as can food preferences (there are taste receptors in our digestive tract). Plus, total-calorie expenditure goes up afterward, possibly because the body has to work harder to digest food, he says.

It’s a different physiological state than actively dieting, and people gain weight back much more slowly following surgery, says Dr. Lofton. Patients can expect to see some re-gain after five years or longer, whereas people who lost weight with diet and exercise start getting the creep after six months to a year. “Bariatric or metabolic surgery, as we now call it, is shown to be the most effective weight-loss therapy that we have,” Dr. Lofton says.

But it’s not as accessible as you might think. Insurers need to approve people for procedures based on their height, weight, and related medical conditions — and this assumes you have insurance and your employer doesn’t exclude these treatments. According to Dr. Lofton, this is weight bias. “You wouldn’t exclude someone’s diabetes medication, but when we’re treating this condition, employers can and have opted to exclude coverage for these practices.”

“Because our society has taught many people that weight is a control issue or a matter of patient preference and not a medical condition — even though it is considered to be a medical condition in the medical community now — we see this bias regarding treatments for any type of weight management, from seeing a specialist, like myself, to surgery, and I think it’s shameful.”

And, not for nothing, but the numbers on the scale shouldn’t be the only focus. Dr. Rosenbaum says that, too often, we take weight as a proxy for our health. People who’ve lost even a small amount of weight and kept it off should be extremely proud of themselves, even if it’s short of the number they wanted to hit, he says. (In someone with obesity, a 5 percent weight loss is enough to help improve their health.)

Dr. Butsch emphasizes to his patients that better health is the ultimate goal. Getting better sleep and lowering stress are worthy efforts, too. And perhaps some people will ultimately be satisfied by not gaining any more weight. “We have to make lifestyle changes that are going to improve our health; they may not improve our weight,” he says. “We expect them to help us with weight loss, but if that’s our only focus, we might be set up for not meeting our expectations and then getting discouraged that we’re not continuing to lose weight despite our best efforts.”

Sometimes, weight is just a stupid number, he says. “Tell me about how you are able to do things that you weren’t able to do before. Tell me how you’re more intimate with your partner. Tell me how you feel more confident and you’re able to fit into clothes and tie your shoes. There’s so many other non-weight-loss outcomes that we should focus on that should get us off of this topic of failure and success.”

Why the Obesity Conversation Needs to Change