Weight Loss? No Easy Answers

"Usually when a new medicine happens, we have time to learn how to use it. [But with GLP-1 drugs], everyone is kind of iterating in real time." 

"For the first time, we have medications that target obesity at its root, reshaping how the brain and gut regulate hunger and impact metabolism. These breakthroughs are game-changing, but major barriers remain: high costs, insurance hurdles, lack of real-world data in diverse populations, and persistent stigma."

"Both of them [Ozempic and Wegovy] slow stomach emptying. Both of them decrease appetite. Both of them work at the level of the pancreas and at the level of the brain and other organs in the body."

"It is a blockbuster in the works. [The weight loss it produces is] profound [and might be a good fit for people with a very high BMI]."

Dr. Melanie Jay, director, N.Y.U. Langone Comprehensive Program on Obesity 

 

"Not everybody responds to GLP-1." 

"[Other] people are having tolerance to it. … Over time, somebody who responded to Wegovy really well at the beginning, five, 10, 20 years from now, probably will need some other more powerful or different acting medication."

"For somebody who has a lower BMI of 30, this might be overpowering."

Dr. Shauna Levy, medical director, Bariatric and Weight Loss Center, Tulane University, New Orleans 

 

"Just as there are many classes of medications for diabetes or for blood pressure, there will be many different classes that target different mechanisms of the disease of obesity."

"They are all hormones that communicate to our brain. How hungry are we? How full are we?"

Dr. Ania Jastreboff, director, Yale Obesity Research Center

Alvvino

 

World-wide, tens of millions of people take prescribed drugs like Ozempic. A situation that represents a type of real-time experiment offering substantially greater data than would be the case with even carefully controlled clinical trials. Originally prescribed as a weight-loss drug for people with diabetes, the drug has greatly expanded in use beyond diabetes and obesity. Some of the class have been approved for the new purpose of reducing risk of heart attacks and allied cardiovascular issues as well as for the treatment of sleep apnea, severe liver disease, and kidney disease.

 

While the drugs' use has been expanded now to treat a wider variety of health conditions, it is widely acknowledged that it is their weight loss performance that drives their wider use. On the other hand researchers subscribe to the belief that the drugs provide benefits other than weight loss. Leading that  belief is a theory that the drugs' effect diminishes the opportunities for inflammation, involved in many chronic health conditions.

 

Those patients who decide to cease taking the drugs tend to regain weight to a significant degree. Clinical trials of the injectable drugs now in circulation have noted that people lose some 15 to 20 percent of their body weight on average after roughly 72 weeks; numbers supported by other studies. Depending on the drug and the study other real-world  trials indicate average weight loss to range between 8 and 17 percent. 

 

When people  decide to stop taking the drugs it is most often attributed to the result of unwanted side effects, or the costs involved. At least some of the dropped weight will be regained. Records of 180,000 patients underwent an analysis that found over half of those who took semaglutide -- the working substance of Wegovy -- or tirzepatide -- the compound in Zepbound -- retained at least some lost weight or even additional weight two years post-cut-off. 

 

GLP-1 drugs for diabetes and weight loss have proven to be very effective, but they do have side effects. Among those side effects is "Ozempic face," where skin on the face sags and wrinkles. "Ozempic face" was coined in reference one of these drugs, although any rapid weight loss can cause it. Harvard Health

 

Patients stopping use of the drugs frequently select other methods to maintain weight loss, including intense exercise, bariatric surgery or other weight-loss medications, according to Hamlet Gasoyan at the Cleveland Clinic in Ohio, who studies these drugs. Unexpected downsides can result with many people on the drugs experiencing side effects reported in clinical trials, such as nausea, fatigue and digestive issues like vomiting and diarrhea.

 

With ever greater numbers making use of the drugs, additional concerns crop up, such as "Ozempic breath" (dehydrated patients whose dampened appetites cause them to consume fewer liquids), and "Ozempic face" that results after fat loss leaves a hollowed-out appearance on the face. More serious issues have also emerged with doctors seeing dialled-down appetites sufficiently extreme to end up with some patients developing nutritional deficiencies.

 

The loss of muscle mass in some patients, another issue -- with many young, healthy patients able to recover or preserve muscle by strength training and consuming more protein, according to doctors. Older adults, however become more frail on these medications, and the risk of falls becomes more troubling. There are some who use the drugs who claim to feel more confident, able to exercise and move about with greater ease. 

 

Other patients claim, according to Marie Spreckley, a researcher at University of Cambridge, that they feel emotionally flatter, abandoned by the delight they once held for food, leaving them less connected to the social element of eating with others. Even others report personalities that feel dull, or being left feeling lethargic under the influence of the drugs. 

 

For many years, patients struggling with weight loss were told that success simply required more willpower – eat less, exercise more and the weight would eventually come off. But recent advances in medical science prove it’s often not that simple. The Science of Health

 

A Conundrum of Obesity in Canada's Armed Forces

Canadian soldiers get ready to leave Camp Julien in Kabul, Afghanistan, Nov. 29, 2005. THE CANADIAN PRESS/AP

"I think DND [Department of National Defence] was hiding the records because they're embarrassed."

"This is information that people have a right to know and information of consequence. Is the military fighting fit or not?"

"DND claimed it had no such records even though the briefings clearly have a DND and Canadian Forces logo on them."

Researcher Ken Rubin

"CAF [Canadian Armed Forces] surveys also study eating patterns, barriers to  healthy eating, and chronic conditions."

"BMI at the population level is a practical and useful tool, especially to compare data over time, even if it has limitations."

"[The Canadian Forces does not track data] on the number of members who have been subject to administrative action or release in relation to physical fitness issues that may cause medical employment limitations."

"An administrative review determines the most appropriate action, if any, to deal with the matter, and is  conducted in a transparent manner with a focus on procedural fairness."

DND spokesperson Andree-Anne Poulin

Sixty-eight per cent of Canadian men were considered obese or overweight, while that rate was 78 per cent for men in the military, according to Canadian Forces briefings. Photo by Canadian Forces

In 1989 when the Canadian Armed Forces were at full staffing levels -- which they are not now at -- an interior study concluded that five percent of the 88,000 regular force was judged to be obese, and another 17 percent was considered to be overweight. At that time, 15 percent of Canadians were thought to  be obese, while 15 percent were seen to be overweight. Qualifying any serving member of a military as obese or overweight does not augur well for fitness to serve in combat roles in defence of their nation.

Fast forward to the present era, and what was seen as deplorable decades earlier seems in retrospect slight numbers of questionable fitness of individuals to serve in the military. As evidenced by shocking new data revealing that troops enlisted in the Canadian military have degenerated to the point where 72 percent of armed forces personnel fall into the categories of overweight and obese. Senior leaders were evidently warned of this increasing phenomenon of unhealthy fitness levels in the Forces in June 2024 contained in briefings warning that "Obesity prevalence has been slowly increasing for many years". 

One of the results of which has been an increase in sick days and medical releases, as well as reduced readiness and productivity in the pursuit of the profession. And this, at time when recruitment is at an historically low level. In the Canadian Armed Forces, today's reality is that forty-four percent are categorized as overweight, and 28 percent are classified as obese. Such briefings for leaders of the army, navy and airforce were not released to the public domain, but were revealed through applications to the Access to Information Act by Ottawa-based researcher Ken Rubin.

The Canadian Military, it transpires, has  higher rates of both overweight conditions and obesity than is prevalent in the general population. The briefings revealed that in comparison to the numbers of obesity and overweight in the military, for the general population, sixty-eight percent of Canadian men are considered obese or overweight in comparison to the 78 percent with those health conditions in the military. Embarrassing statistics which explain in part why they were never released for public scrutiny.

In the military, for example, 57 percent of women enrolled in the military are either overweight or obese, as opposed to women in the general population whose numbers in those categories total 53 percent. One report stated that "increasing physical activity levels will not resolve the challenges of obesity in the CAF". Military health specialists suggest the promotion of a culture of fitness through physical activity combined with injury prevention, adequate sleep and proper nutritional intake.

Mr. Rubin's request for data from the military through the Access to Information Act went unfulfilled; the response from the military was to inform the researcher that no such information existed. Finally, Mr. Rubin submitted  his request to the Canadian Forces Morale and Welfare Services, separate from DND, and from them he was able to obtain 141 record pages, including the briefs produced by DND on physical fitness in the ranks.

Short sleep duration (fewer than 6 hours) and borderline short sleep duration (6 hours to fewer than 7 hours) were independently associated with increased odds of obesity for male CAF members, but not for females. These results take into account differences in a range of other factors, including sociodemographic, work and health characteristics of CAF members.

Shorter-than-recommended sleep duration, poor sleep quality and obesity are concerns for long-term health, wellbeing and deployment readiness of the military population. Sleep has been identified as an important aspect of physical performance in both the CAF and the US military. Because sleep affects energy balance, eating and physical activity behaviours, it has been identified as a potential tool to aid in managing obesity. Longitudinal or intervention studies are needed to better understand the potential role of healthy sleep practices in obesity management, particularly in military populations.

Statistics Canada

Emerging Weight-Loss Strategies, Pharmaceuticals

"This time around we know much more about the biology and patho-physiology of obesity."
"Everyone [clinicians, before 2010, convinced that people could be spurred to burn more calories] felt that if we could just get a medication that increased metabolic rate, that would work."
"Everything starts moving faster and causes lots of problems [when metabolism is chemically driven]."
"[For full safety effects with the use of some drugs] you need years on a drug. But at the very least, we're showing people are staying on the medication for a longer period of time, because it's tolerable, and it's working [new generation of drugs]."
Dr.Sean Wharton, internal medicine specialist, McMaster University

"Every medication industry goes through its 20 or 30 years of nonsense, where nothing works and things aren't safe."
"We're coming out the other side now. We have effective and safe medications that are already making significant changes in someone's ability to lose weight and keep it off."
Dr.David Macklin, medical director, weight management program, Mount Sinai Hospital, high risk/special pregnancy BMI unit, Toronto

"However you look at it, obesity is deleterious for health - functionality, mental health and metabolic health. [The history of medical treatments, early anti-obesity pills] has been a bit of a train wreck."
"[But] drugs will be important for the management of obesity and, I think, especially for weight loss maintenance."
"With the new acceptance of injectable [peptides] we will have more success and probably less side effects."
Dr.Eric Ravussin, editor-in-chief, Journal Obesity, associate executive director, clinical science, Louisiana State University Pennington Biomedical Research Center, Baton Rouge

A 2018 study in the Lancet Diabetes and Endocrinology points out that people mostly regain at least some of the weight they shed, a year after beginning a new, successful protocol that allows them to shed at least 5 percent of their weight. And though 5 percent doesn't seem like much, given peoples' propensity to be overweight in this modern world, it is frequently considered just enough to see improvement in weight-related health problems such as pre-diabetes and high blood pressure.

An estimated ten million Canadians actively engage on a diet on any given day of the week. Irrespective of what comprises the dieting, according to Dr.Daniel Bessesen of the University of Colorado, and Dr.Luc Van Gaal, University of Antwerp, once weight is dropped, the body tends to dial down energy expended at rest, undergoing alterations in insulin sensitivity favouring fat storage. "Long-term studies suggest that these changes are probably permanent", they caution.

Add to that the fact that not everyone is able to use anti-obesity drugs, and those who can benefit from their use must continue taking them if the intention is to keep weight down. "Weight increases gradually to the level seen with lifestyle changes alone", according to all studies of anti-obesity medications which conclude this outcome when the individual decides to stop taking the medication.

When leptin, the hormone known as an appetite-suppressant was discovered, scientists felt they had discovered the cure for obesity, until the revelatory understanding that many obese people are not deficient in the hormone, but rather are resistant to it.

After years of dismal failure with emerging drugs viewed as weight loss winners, but which later studies indicated were instead beginning to cause an epidemic of serious heart-valve problems in people with no known history of cardiac disease, the drugs were removed from the market, after millions of people had begun their use. Decades on, the pharmaceutical industry is returning anti-obesity drugs to the marketplace. Between the years 1975 and 2016, obesity has tripled among the general population.

It remains unknown why this has been occurring, although educated guesswork brings up less physical-oriented lifestyles and the normalization of the consumption of convenience, ultra-processed foods, along with the vast array of foods now available. While the common origins of the increasing rise in obesity is not yet understood, what medical science does acknowledge as fact is that once weight is gained, it becomes inordinately difficult to lose, and once lost, it then becomes even more difficult to maintain that loss.

To date, bariatric surgery is acknowledged as the most successful treatment for obesity, but many people cannot qualify for the surgery, or would prefer not opting for invasive surgery which has its own potential risks. And then there is the surgical wait list, of up to eight years. So the prospect of next-generation drug treatments for obesity has its obvious allure. Drugs of various types are beginning to emerge and tests carried out to determine their feasibility. Some of which have side effects that include nausea, constipation and diarrhea.

And then there is the recognition that the problem of obesity cannot be addressed by drugs alone even as two thirds of Canadians are recognized to be living with an overweight condition, or obesity. And for these people attempting to lose weight, the situation is that all anti-obesity drugs approved for use in Canada must be used in conjunction with a reduced-caloric diet and exercise plan. Some of the medications cost up to $4,000 annually, none paid for by provincial public drug benefit plans, whereas in the U.S. guidelines recommend such treatments only for those carrying a BMI of 30 or greater.

A group of girls wait for the start of a water aerobics class in Reeders, Pennsylvania. 

William Thomas Cain | Getty Images

Lifestyle Habits : You Decide

"Obesity is unique in that some doctors and much of society feel comfortable moralizing about it."
"Lifestyle has the ability to both treat and prevent a ton of medical problems, but the only one we seem to moralize about is obesity."
Yoni Freedhoff, co-founder, Bariatric Medical Institute, Ottawa

"It's clearly absolute nonsense to think that the current obesity crisis has been caused by a deficit of willpower."
"For that to be true, willpower would have had to have collapsed in every continent of the globe simultaneously across men, women, people of all ages. It's really bizarre that we still want to view that as the main cause of obesity rather than looking for environmental causes, but people just cling onto these ways of thinking."
"We're living in a world in which we're being sold a huge surfeit of calories every day. So you can easily become overweight or obese just simply by choosing among the affordable foods that are available to you."
"We should be so much more critical of the people selling us the food, and so much less critical of ourselves. It makes me upset to think about how many people, especially women, internalize this huge sense of guilt around food and a sense we should be doing better, and we're lacking in willpower when actually the choices we're being offered are crazy. Completely crazy, inhuman levels of choice."
"I just wish we would stop beating ourselves up so much and stop believing there has to be one absolute true answer. Because food isn't really like that. As omnivores, we've always eaten a range of foods; we've muddled along, we've adapted to environments. That middle ground gets lost."
Bee Wilson, author, The Way We Eat Now

"As insulin goes up, the body stores body fat. That's the job of insulin, to tell our body to store body fat. If insulin does not go up, then your body will use it in other ways. It won't store the body fat."
"If you eat 100 calories of cookies versus 100 calories of avocado, the minute you put it in your mouth, the hormonal response is completely and utterly different."
"If you eat cookies, insulin goes up and  your body stores body fat. If you eat avocado, insulin does not go  up. Your body tends to burn body fat because it still needs energy to run the liver and so on."
"All diets work in the short term. But we've been ignoring the long-term problem of insulin resistance. [The solution is to establish the balance between feeding and fasting]; We get so bogged down in carbs and fat and protein that we lose sight of the really important thing. And that's where I wanted to refocus people; 'Hey, we need to look at this meal timing question because it's a question of what to eat and a question of when to eat."
Jason Fung, nephrologist, Toronto author, The Obesity Code

Teenagers, according to Psychology Today, who think of themselves as overweight are so burdened with the vision of themselves as unattractive, unreflective of the ideal body shape, they are likelier than other teens to attempt suicide and to suffer depression. This, aside from the fact that we are killing ourselves, slowly but surely; shortening our lifespans, exposing ourselves to greater likelihood of acquiring life-sapping chronic diseases, by our lifestyle choices; above all by the kinds of food we energize our bodies with.

A major study published recently in The Lancet medical journal points out that poor diets kill 11 million people globally every year, more people dying of that cause than those who die as a result of tobacco use and second-hand smoke. Food security is viewed as having an impact even in developed countries such as Canada as well as elsewhere, while generally speaking most people live with a plethora of food choices. Rates of overweight and obesity have tripled since the mid-1970s.

Obesity is linked to increased risk of many disease, including some cancers, heart disease, high blood pressure, and Type 2 diabetes -- which itself can lead to the previously-named conditions. We are faced with a situation where omnipresent food advertising and the ready availability of calorie-dense, nutrition-absent food rules society. Never has that old adage, "everything in moderation" been more critical to healthy outcomes than at the present time. "Eat less, move more", seems like a simple formula for attaining and maintaining better health, but it seems to fall on deaf ears.

When combined with healthy eating, regular physical activity will help you lose weight and stay at a healthy weight.

In a survey of over 1,500 American adults, three-quarters of the respondents reported their belief that the best treatment for obesity is summoning the self-discipline to go on a diet. Scientific evidence appears, confoundingly, to reject that belief, citing the fact that most grocery supermarkets offer up to 40,000 different food products. Even visiting one of the ubiquitous convenience stores exposes consumers to a wide array of convenience food products, foods whose wholesome quality has been processed and adulterated.

So yes, we should be critical of the manufacturers of this ersatz food. And we should tune out the advertisements that we and our children are exposed to constantly. We should indulge from time to time in a bit of introspection, gauging the food choices we select and going a little further to imagine how healthy those choices are, and what, in the final analysis they do over time to our bodies. The thing of it is, most people can't bother, because they're busy, distracted, time is short, and truth to tell the very thought of preparing whole foods to form a nutritious meal is unappealing.

In this social climate it isn't only the food processing manufacturers that can be held responsible for appealing to peoples' willingness to buy pre-prepared meals heavy on taste-good but lethal amounts of salt, fat and sugar, but those on the other end of the spectrum whose existence is dependent on the desperation of people to lose the extra weight they gain from improvident food choices, who offer a dizzying array of fad diets. Consumers accustom themselves to buying food geared to put on weight, and when they become overweight and obese look for quick solutions to lose that weight.



And along come diets like keto, paleo, carnivore, pegan and fodmap, among the many others that proliferate and promise solutions. Weight loss is celebrated, and soon afterward what melted off returns. Simply because most people after losing weight, lose the diet and return to their 'normal' food consumption habits. A professor of psychology at the University of Minnesota in 2013 updated an exhaustive review  of diets, along with a two-year follow-up. Professor Traci Mann found that while people lost weight in the first nine to 12 months, the following two to five years saw them regain it all with the exception of one kilogram (2.1 lb.).

As for a non-dieter group used for comparison, they gained an average of 544 grams (1.2 lb.) over the same period. In her article published in the American Psychological Association, Professor Mann summarized the situation such that "the dieters  had little benefit to show for their efforts, and the non-dieters did not seem harmed by their lack of effort." This, in an era where advocates of good health succeeded in having all prepackaged food labels reflect calories related to the constituents of the food enclosed in those packages.

Instead of curtailing eating habits contributing to increased rates of obesity, Type 2 diabetes, hypertension and other diseases, national health organizations such as the Canadian Diabetes Association, Heart and Stroke Foundation continue to support calorie counting. According to Dr. Fung, caloric reduction does not reflect a realistic option for weight loss: "It's my opinion that this doesn't work. Look at the obesity epidemic. The only thing (doctors) ever said was 'calories in, calories out'."

Dr. Fung champions another regimen; meal timing. Fasting routinely. In that at one time in the not so distant past people were accustomed to eating breakfast, then fasting, eating nothing else until the evening meal. Breakfast at 8 a.m., dinner at 6 p.m.; ergo a 14-hour fast. 

"There are a handful of trendy, reputable, diets people follow and see positive results on, including keto, Paleo, Whole30, and intermittent fasting. Now, a recent study published in the journal Obesity found that intermittent fasting is an effective way for women who are overweight and obese to drop excess weight. Technically, IF is not a diet that instructs you on what to eat, but rather an eating plan that tells you when to eat, and it involves committing to a cycle of eating and fasting within a set amount of time. See the difference? This study showed that women not only lost weight, but they improved their overall health as well."       
Cheyenne Buckingham, Eat This, Not That!