There are 2 important papers this week that patients should know about.
Let’s start here:
“I’ve lost the weight before, doctor. It just came back months later.”
It’s a common story in clinic, and there is science behind it. This paper came out this week and it’s about that science of weight “yo-yo’ing”. Let’s talk about why it’s important.
Firstly, if you are new to following, let’s establish where we are starting:
Obesity is a complex, chronic, progressive, and recurring disease. Let’s break that down: That means that we are in no way concerned about beauty or aesthetics. Every body is beautiful. When weight impacts health — that is disease. In obesity, a patient usually doesn’t have one cause for obesity, there are multiple risks that add up together. This becomes a long term condition. Health complications (hypertension, joint pain, sleep apnoea, heart disease, subfertility, psychological stress, asthma, diabetes, liver disease…) continue to progress. We know that no matter how we treat obesity, there is a substantial risk of weight recurrence – that is, the weight comes back on.
The Science of the Weight Yo-Yo
Actually called “weight cycling”, this is the pattern all patients know: they lose the weight, the weight comes back – with a little extra, and repeat. It is frustrating and frankly demoralising. Patients are often drawn into patterns of using increasingly restrictive fad diets, punishing gym routines, supplements, downloadable apps for each cycle. And it’s not by accident: The diet industry is worth €€€€ and they make their money by promoting the ideas that 1) your weight and your self worth are somehow connected 2) it’s your fault if you can’t lose the weight and keep it off 3) their programme is going to the the one that FINALLY works for you. Commercial slimming programmes may help some people maintain a healthy weight or lose a small percentage of weight (around 5%) — but should not be seen as a treatment for the complex, chronic, progressive, and recurrent disease of obesity which usually requires qualified and ongoing medical support.Note: there is a BIG difference between the evidence-based strategies that work in the prevention of obesity/maintaining a healthy weight — and what we know is needed for treatment of established obesity.
While we are here: do I even have to say again that weight is not beauty? I do say it alot! Every body is beautiful. Where weight is a medical problems — that is putting patients at risk of heart disease, diabetes, joint pain, sleep apnoea, stroke, asthma, liver disease…. — it deserves medical treatment.
The Science of the Weight Yo-Yo
Actually called “weight cycling”, this is the pattern all patients know: they lose the weight, the weight comes back – with a little extra, and repeat. It is frustrating and frankly demoralising. Patients are often drawn into patterns of using increasingly restrictive fad diets, punishing gym routines, supplements, downloadable apps for each cycle. And it’s not by accident: The diet industry is worth €€€€ and they make their money by promoting the ideas that 1) your weight and your self worth are somehow connected 2) it’s your fault if you can’t lose the weight and keep it off 3) their programme is going to the the one that FINALLY works for you. Commercial slimming programmes may help some people maintain a healthy weight or lose a small percentage of weight (around 5%) — but should not be seen as a treatment for the complex, chronic, progressive, and recurrent disease of obesity which usually requires qualified and ongoing medical support.
Note: there is a BIG difference between the evidence-based strategies that work in the prevention of obesity/maintaining a healthy weight — and what we know is needed for treatment of established obesity.
While we are here: do I even have to say again that weight is not beauty? I do say it alot! Every body is beautiful. Where weight is a medical problems — that is putting patients at risk of heart disease, diabetes, joint pain, sleep apnoea, stroke, asthma, liver disease…. — it deserves medical treatment.
What is it?
It’s a paper from Nature (so what we call “high impact” journal). You can read the original here: https://www.nature.com/articles/s41586-024-08165-7
What are “epigenetics”?
Epigenetics refers to changes in how a gene is expressed without changes to the DNA. During our life, our DNA doesn’t change but things like our environment and lifestyle factors and diet and disease can cause chemical markers that alter how that gene is expressed.
What does this mean for obesity?
Living with the disease of obesity may be causing epigenetic changes. That means this may explain why even when many patients with obesity lose weight, there is a significant risk of weight recurrence later.
What are 3 things that this paper can tell patients?
1. Despite all the noise from the pharmaceutical industry, we likely should be focusing more on prevention and early intervention of the disease of obesity than treatment of the disease! This includes policies addressing determinants of health like ultra-processed foods, poverty, health literacy, healthcare access.**
2. While the availability of GLP-1a drugs (like semaglutide/Ozempic) have been a game changer for many patients, this may show that in the longterm, these treatments have limits (beyond the limits we already know!)
3. If a patients loses weight, it may be very difficult to keep the weight off, despite a patient’s best efforts and patients deserve access to ongoing evidence-based supportive care — without blame or stigma.
The Editorial (opinion) part:
**Note that in this, I disagree with the author who focuses on that we should just be looking a more treatments to address memory cells. It is true that we need better treatments for patients who have the disease of obesity. However, if we look at the epidemiology of the obesity – that is, how many people have obesity now compared to how many people had obesity 20 years ago or 50 years ago – we should be very concerned about what has changed in our world that so many people now have this disease. This is of urgent concern to children, and strategies to prevent obesity in children and younger adults should be a focus now – since the evidence continues to grow that once the disease of obesity is established, long term treatment will require more options than we have right now.
It’s really like any disease. For example, when it comes to cancer, we are all thrilled to see more effective treatments. However, we would all prefer just to prevent the disease entirely or at least to have the opportunity to intervene at earliest stages.
Losing weight: Fat or Muscle?
The second paper is from Metabolism and explores how patients on these drugs may be losing muscle – not just fat. In fact, this topic is really important and there was a second paper about his same thing in The Lancet Diabetes and Endocrinology. What should patients know?
This is an important reason that patients on these drugs should also have whole patient expert care – not just drugs. Personal trainers or “nutriionist” are not medically qualified to be monitoring patient progress on these drugs. The goal of care should be health gains – not just moving a number on the scale.
Losing muscle isn’t good, and many people with obesity also have sarcopaenia (less muscle than they should have). Muscle is important not just for strength, but also for things such as healthy metabolism and healthy aging.
These papers are behind a paywall, but if you have institutional access: https://www.sciencedirect.com/science/article/pii/S0026049524002853 and https://doi.org/10.1016/S2213-8587(24)00272-9
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