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While sensible lifestyle changes are the key for long-term success, there are many options a person could consider when making the initial choice about losing weight. The following information is designed to cover the main types of weight loss approaches.

» Eating Plans » Dietitian
» General Advice » Weight Loss Supplements
» Advice for Weight Loss » Drug Therapy
» Very-Low-Energy Diets » Surgery
» Meal Replacements  

Eating Plans

Contrary to the claims of fad diets, no single food plan is a guaranteed way to weight loss success for every person, and no specific food must be included or avoided in a weight-management program. In designing a plan either alone or with a weight management consultant, people should consider foods that they like or can learn to like, that are available, and that are within their means.

There certainly is no one-size-fits-all approach, but many of the following principles should appear in your eating plan and be promoted by anyone offering a credible tailored weight loss plan.

General Advice

  • Focus on healthy eating and activity habits, not on weight losses or gains.
  • Eat regularly, and don’t skip meals, especially breakfast.
  • Adopt reasonable expectations about health and fitness goals and about how long it will take to achieve them.
  • Make nutritional quality of the food you eat a high priority.
  • Learn, practice, and follow a healthy eating plan for the rest of your life.
  • Participate in some form of physical activity regularly.
  • Adopt permanent lifestyle changes to achieve and maintain a healthy weight.

Advice for Weight Loss

  • Energy out should exceed energy in by about 2100 kilojoules (500 Calories) per day. Increase your physical activity enough to spend more energy than you consume from foods.
  • Emphasise foods with a low energy density (typically foods lower in fat) and a high nutrient density (usually unprocessed foods).
  • Eat small portions. Share a restaurant meal with a friend or take home half for lunch tomorrow.
  • Eat slowly
  • Make legumes, whole grains, vegetables, and fruits central to your diet plan
  • Limit treats to the serving size on the label.
  • Limit concentrated sweets and alcoholic beverages.
  • Water is always a better choice than soft drinks and even fruit juice. Drink a glass of water before you begin to eat and another while you eat. Drink plenty of water throughout the day.
  • Keep a record of diet and exercise habits; it reveals problem areas, the first step toward improving behaviours
  • Learn alternative ways to deal with emotions and stresses rather than turning to food.
  • Attend support groups regularly or develop supportive relationships with others.

Very-Low-Energy Diets

Very-low-energy diets (VLEDs) are sometimes used in the treatment of morbid obesity. Such a diet provides only 1700 to 3300 kJ per day (less than 800 Calories). To achieve such a low kilojoule diet and still meet the body's protein, vitamin and mineral needs, the use of a specialised liquid meal is required as the source of nutrition. Such diets need medical supervision and should only be used for a period of up to four months. As expected, weight loss on such a diet is dramatic (1.5 to 2.5 kg per week in obese people) yet long-term weight loss success is not superior to other conventional weight loss approaches. VLEDs can be helpful with initial weight loss in morbidly obese people, but behavioural therapy and lifestyle changes are needed to increase the likelihood of maintaining some of the weight loss.

Meal replacements

Meal replacement shakes, bars and soups are sometimes popular options to help control weight. The products are designed to replace one or more of your daily meals, but are not a substitute for your entire normal daily food intake. Meal replacement products are usually very low in fat and often have added fibre. If used as part of dietary changes, meal replacement products have been shown in clinical trials to produce a weight loss of 3 to 9.5 kg over one to five years. When combined with counselling by a dietitian, meal replacement products may be even more effective. Partial meal replacements seem to be safe and more effective over the long-term than most other diet-based weight loss techniques. The main downside to these products is that they can be expensive.

Dietitian

If you want professional advice with weight loss, seeing an accredited practising dietitian (APD) can be a good option. Dietitians are university qualified professionals with expertise in applying the science of nutrition to help people understand food and health relationships and make food choices to achieve good health and enjoy a healthy lifestyle. A dietitian can develop personalised eating plans based on your current health, job, lifestyle, past medical history, food preferences, food access and cooking skills, and provide ongoing support, advice and guidance. All Council members have in-house consulting dietitians.

Weight loss supplements

Because weight loss is difficult to achieve, there is an abundance of supplements and alternative treatments that offer the promise of quick and effective weight loss. Many of the claims made by these products have little scientific proof to back them up. Many popular products have been tested in controlled trials and there is little evidence to support any of them having a significant benefit in weight loss. Most products promote an energy controlled diet combined with exercise, which if followed, would explain any weight loss seen while taking the product.

Popular over-the-counter weight-loss supplements Proposed method of action
Caffeine/Guarana Increases metabolic rate
Carnitine Fat 'metaboliser'
Chitosan Inhibits fat absorption
Chromium picolinate Improves insulin sensitivity
Gingko biloba Stress reduction leading to reduced appetite
Grapeseed extract Antioxidant; benefits circulation
Lecithin Increases transportation of fat
Sweet clover Estrogen-like properties; increases circulation
St John's wort Natural antidepressant may lead to reduced appetite

If a miracle supplement existed, obesity rates would be in rapid decline, but unfortunately that is not happening. While some supplements may provide a small benefit that is difficult to measure in a scientific study, most of them of are of little value. Rather than spending your money on supplements of questionable benefit, perhaps invest in a good pair of walking shoes and a pedometer instead. The next time you are tempted to try a newly released 'breakthrough' supplement be especially wary if some of the following claims for the product are made:

  • Fat burner, burn fat, fat trapper or fat blocker.
  • Quick and easy weight loss.
  • Secret formula or ancient formula.
  • Weight loss breakthrough or scientific breakthrough.
  • Weight loss without dieting or exercise.
  • ‘Secret’, ’magical’, or ‘synergistic’ ingredients.

Other gimmicks do not help with weight loss either. Hot baths do not speed up metabolism so that kilograms can be lost in hours. Steam and sauna baths do not melt the fat off the body, although they may dehydrate people so that they lose water weight. Brushes, sponges, wraps, creams, and massages intended to move, burn, or break up “cellulite” do nothing of the kind.

Be wary of 'miracle' weight-loss cures seen on ‘current affairs’ programs or infomercials, where the evidence is likely distorted and mostly based on anecdotes and testimonials. Obesity is a chronic disease that cannot be cured overnight with creams, wraps, gels and pills.

Drug therapy

There are only two approved drugs available in Australia specifically targeted for weight loss and that’s the intestinal lipase inhibitor orlistat (Xenical™) which is available ‘over the counter’ from pharmacies, and the prescription-only medication Phentermine.

Orlistat works by inhibiting the enzyme that breaks down fat in the intestine. This results in about 30% of ingested fat remaining unabsorbed. People taking orlistat have to follow a low-fat diet to minimise unpleasant gastrointestinal side-effects from fat malabsorption. Most of the weight loss when taking the drug is due to dietary changes because of the risk of gastrointestinal consequences of a high fat diet, not because of the reduced fat absorption. In Australia, orlistat is available over-the-counter through pharmacies though has restrictions for its sale. On average, people who use orlistat lose about five percent to ten percent of their original weight.

Phentermine works as an appetite-suppressant by changing the brain's serotonin level, thereby, affecting neurotransmitters' metabolism. Phentermine can have side effects such as rapid heartbeat, constipation, dizziness, alertness and insomnia and is recommended for more short-term use under the care of a doctor.

While drug therapy may seem like an attractive option to help with weight loss, there is no known 'cure' for obesity and only modest weight loss reductions are seen using drugs. Drugs do have side-effects and their long-term safety is still unclear. The cost of obesity drugs is not covered under the PBS (Pharmaceutical Benefits Scheme) hence the ongoing need to take these medications can represent a significant financial cost for the user.

Surgery

Surgery for obesity: information for consumers
Surgery for the treatment of obesity is known as bariatric surgery. It is a treatment option for severe obesity particularly when complications are present. There are a number of different types of operations that can be performed. The surgery may involve the stomach, intestines, or both. All operations physically limit the amount that can be eaten. Some operations also affect digestion and absorption of food and change the way the gut signals to the brain via signalling substances in the blood (hormones) and/or specialised nerve pathways.

When should surgery be considered?

  • Severe obesity accompanied by a one or more obesity related conditions (for example diabetes, heart disease, sleep apnoea), or is affecting mobility and ability to function normally.
  • When well-informed about the different types of operations and the risks and benefits of each preferably by someone independent to the surgeon.
  • Understand exactly what the consequences of the operation will be for your life, the risks and benefits, and the types and amounts of food that can be eaten.
  • After you have commenced a plan for healthy eating and regular physical activity and committed to continuing for that life.
  • If you are willing to comply with the need for regular medical follow-up and to take extra vitamins and minerals each day.
  • Choose the surgeon based on the operation you consider best for you and clarify that the surgeon is proficient at performing the particular operation you want. If not ask your GP for a referral to a surgeon who does have the requisite expertise.

Although surgery has the best long-term outcomes for achieving and maintaining weight loss it does not replace the need for a healthy diet and regular physical activity. Unless this is something you have already commenced and intend to continue on an ongoing basis then you are not ready to have surgery.

What are the different types of operations and what are the benefits and risks of each?

  • Differences between open and laparoscopic surgery:
    • “Open” approaches involve cutting through the wall of the abdomen.
    • Laparoscopic surgery, more commonly known as “keyhole surgery” requires small 1 cm cuts through which the surgeon can guide a small camera and instruments to perform the operation. This is associated with less tissue damage, quicker healing, less risk of hernias, and a shorter hospital stay.
    • A laparoscopic approach is not suitable for everyone. For example, people with extreme obesity or who have had previous stomach surgery.
  • Types of bariatric procedure
    There are three types of operation in routine use in Australia: Laparoscopically placed adjustable gastric band (LAGB), Sleeve Gastrectomy (SG), and Roux-en-Y Gastric Bypass (RYGB)

    Laparoscopic adjustable gastric band (LAGB): although this procedure has been popular in Australia it is done infrequently in the rest of the world, and there is evidence that Australia is following that trend.

    What is the procedure? A hollow band is looped around the upper part of the stomach. As a result, a small pouch that is separated from the main part of the stomach is created. A balloon within the band connects to a port placed just under the skin of the abdomen. Injecting saltwater into the port inflates the balloon and decreases the size of the pouch opening; withdrawing the fluid does the opposite.

    How does it work? The LAGB works by restricting the amount of food that can be eaten. Small amounts of food distend the pouch leading to a feeling of fullness. Regular pouch adjustments are required.

    What is the expected weight loss?
    Of the three operations the LAGB is associated with the least and also the most variable amount of weight loss. Inadequate weight loss may occur in as many as one in five individuals.

    To what extent do the complications of obesity improve?

  • Type 2 diabetes is much less likely to improve or disappear after a LAGB than with other operations.
  • It is about half as effective as a Roux-en-Y Gastric Bypass in preventing type 2 diabetes (Carlsson, 2012)
  • No better than a conventional weight loss (non-surgical) program for the resolution of obstructive sleep apnoea (OSA) (Dixon et al 2013).


What are the potential complications?

  • There is a 10% chance of “band failure” each year, at best. In some reports this been reported to be as high as 40%. In one series where people were followed over 12 years the failure rate of the procedure after 2, 5, 8, and 10 years was 25.7%, 24.3%, 25.7%, and 31.6% respectively.
  • Abnormalities of the function of the oesophagus (swallowing tube) occur commonly (up to one in four people). This may result in reflux of acid and heartburn and/or difficulty swallowing (Naef et al 2010; Naef et al 2011)

Is the procedure reversible? The procedure is reversible however scarring and thickening around the upper portion of the stomach and abnormal motor function of the oesophagus (swallowing tube) may persist.

Patient satisfaction. 46% very satisfied; 19% unsatisfied or even regretted having undergone the procedure (Browne et al 2006)

Roux- en-Y gastric bypass (RYGB): This operation is technically difficult and requires special training which many surgeons doing operations for obesity have not received. It is the operation associated with the largest and most durable weight loss

What is the procedure? A small pouch is created in the upper part of the stomach. A length of around 100 cm of the small intestine is measured from where it leaves the stomach, divided, and the portion beyond this is joined to the pouch. Staples or stitches are used to create the joins.

How does it work? The small pouch restricts the amount of food that can be eaten. Because the intestine is shortened there is less surface area for digestion and absorption. There is more rapid transit of partially digested food.  The production of hormones (signalling molecules), and signals in nerves that send messages, from the stomach and intestine to the brain increase resulting in decreases in hunger, food cravings, and food preferences and improvements in overall metabolism.

What is the expected weight loss? Around 50 to 70% of excess weight is lost. With good care, most of the weight loss can be maintained in the long term – but this does require regular follow-up. On average people can expect to lose somewhat more weight following a laparoscopic Roux-en-Y gastric bypass (LRYGB) as compared to a laparoscopic sleeve gastrectomy (LSG)

To what extent do the complications of obesity improve?

  • Resolution of type 2 diabetes is more likely to occur after a laparoscopic Roux-en-Y gastric bypass then a laparoscopic sleeve gastrectomy. By six years after the operation the remission persists in 62%. The operation also prevents the onset of new diabetes. By six years after the operation only 2% of people develop new diabetes as compared to around 15% if nothing is done. The likelihood of diabetes resolving with any of these operations is greatest if the type 2 diabetes has been present for a shorter period of time and if insulin is not being used; nevertheless, even if resolution does not occur, substantial improvement and marked reduction in medication use usually follows.
  • Improvements in blood lipids occur and are well maintained.
  • High blood pressure improves markedly over the first couple of years and then tends to increase but still remains lower than it was before the operation.
  • Obstructive sleep apnoea resolves after a Roux-en-Y gastric bypass in 60-80% of people.
  • The procedure is very effective at resolving problematic acid reflux which causes “heartburn”

What are the potential complications? Overall the procedure is extremely safe with a risk of death or a serious complication being the same as with having a gallbladder removed.

Early complications: Bleeding, infection, and leaks from where the intestines have been joined may occur. Also blood clots may form in the veins of the legs and moved to the lungs causing blockages and damage.

Late complications:

  • Narrowing at the site of the joins may occur (strictures), or erosions (ulcers), and hernias may form at points of weakness of muscle in the abdominal wall.
  • Rapid emptying from the pouch particularly of sugars may lead to what is known as dumping syndrome; which is a very unpleasant feeling of fullness, even after eating just a small amount, abdominal cramping or pain, nausea or vomiting, diarrhoea (which may be severe), sweating, flushing or light-headedness and a feeling of rapid heartbeat.
  • Occasionally intractable diarrhoea may occur necessitating reversal of the procedure.  
  • Severe vitamin deficiencies may result in serious ill health.  
  • Loss of bone and an increased risk of fracture
  • Rarely there can be problems with low blood sugar.

Is the procedure reversible? The procedure is reversible although it is a common misconception that it is not.

Patient satisfaction 80% very satisfied no patients regretted having had the procedure (Browne et al 2006)

Laparoscopic sleeve gastrectomy (LSG). Originally designed as an intermediate step prior to doing an RYGB in very large people, the LSG has become extremely popular as a stand-alone procedure.

What is the procedure? During this procedure most of the stomach is removed so that food moves through a narrow tube directly from the oesophagus (swallowing tube) to the intestine.

How does it work? The amount of food that can be eaten is restricted. The hunger producing hormones from the stomach are no longer able to be made. Rapid transit through the gut may be another factor that stimulates pathways reducing hunger and improving metabolism.

What is the expected weight loss? The initial (1-2 year) weight loss is comparable to the RYGB but there is more likely to be weight regain after the LSG so that by 5 years mean excess weight loss is about 10% more after the RYGB (Ignat et al 2017)

To what extent do the complications of obesity improve? Although the LSG improves complications more effectively than a LAGB, it is not as effective as the RYGB.

What are the potential complications?
(Sarkosh et al 2013)
Acute complications

  • Postoperative bleeding occurs somewhere between 1% and 6% of operations
  • Staple line leak is one of the most serious and dreaded complications of LSG and may occur in up to 5% of patients following this procedure
  • Abscess formation deep within the abdomen

Delayed complications

  • Strictures,
  • Nutritional deficiencies
  • This procedure is associated with a significant increase in problematic acid reflux and heartburn requiring medication.

The LSG and RYGB have similar rates of complications over the first 30 days. But more RYGB patients required readmission and reoperation later on, although that varies by centre. Surgeons that do 50 or more operations a year have lower 30 day and longer term rates of complication requiring readmission.

Is the procedure reversible? This procedure is not reversible.

Patient satisfaction: The LSG results in similar improvements in quality of life as does the RYGB

Selected References

Bowne, W. B., K. Julliard, A. E. Castro, P. Shah, C. B. Morgenthal & G. S. Ferzli, 2006.
Laparoscopic gastric bypass is superior to adjustable gastric band in super morbidly obese patients: A prospective, comparative analysis. Arch Surg 141(7):683-9 doi:10.1001/archsurg.141.7.683.

Carlsson, L. M., M. Peltonen, S. Ahlin, A. Anveden, C. Bouchard, B. Carlsson, P. Jacobson, H. Lonroth, C. Maglio, I. Naslund, C. Pirazzi, S. Romeo, K. Sjoholm, E. Sjostrom, H. Wedel, P. A. Svensson & L. Sjostrom, 2012. Bariatric surgery and prevention of type 2 diabetes in Swedish obese subjects. N Engl J Med 367(8):695-704 doi:10.1056/NEJMoa1112082.

Celio, A. C., Q. Wu, K. R. Kasten, M. L. Manwaring, W. J. Pories & K. Spaniolas, 2017. Comparative effectiveness of Roux-en-Y gastric bypass and sleeve gastrectomy in super obese patients. Surg Endosc 31(1):317-323 doi:10.1007/s00464-016-4974-y.

Dixon, J. B., L. M. Schachter, P. E. O'Brien, K. Jones, M. Grima, G. Lambert, W. Brown, M. Bailey & M. T. Naughton, 2012. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA 308(11):1142-9 doi:10.1001/2012.jama.11580.

Ignat, M., M. Vix, I. Imad, A. D'Urso, S. Perretta, J. Marescaux & D. Mutter, 2017. Randomized trial of Roux-en-Y gastric bypass versus sleeve gastrectomy in achieving excess weight loss. Br J Surg 104(3):248-256 doi:10.1002/bjs.10400.

Naef, M., W. G. Mouton, U. Naef, O. Kummer, B. Muggli & H. E. Wagner, 2010. Graft survival and complications after laparoscopic gastric banding for morbid obesity--lessons learned from a 12-year experience. Obes Surg 20(9):1206-14 doi:10.1007/s11695-010-0205-0.

Naef, M., W. G. Mouton, U. Naef, B. van der Weg, G. J. Maddern & H. E. Wagner, 2011. Esophageal dysmotility disorders after laparoscopic gastric banding--an underestimated complication. Ann Surg 253(2):285-90 doi:10.1097/SLA.0b013e318206843e.

Sarkhosh, K., D. W. Birch, A. Sharma & S. Karmali, 2013. Complications associated with laparoscopic sleeve gastrectomy for morbid obesity: a surgeon's guide. Can J Surg 56(5):347-52.

 



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