Commentary: Our understanding of obesity has changed, so must our approach to weight loss

SINGAPORE: Eat less, move more - those who live with obesity may be tired of the same advice every time they see the doctor. Failure to lose weight feels like a shameful lack of willpower.

But what if it wasn’t? Increasingly, experts believe that obesity is not just an issue of willpower and treating it by prescribing a healthier diet and more exercise may not be enough.

Recent research in the journal Nature Metabolism on weight-loss programmes showed that out of people who managed to lose 10 per cent or more of their body weight without surgery or medicine, only 15 per cent are able to maintain it.

The conversation around obesity and its treatment needs to change. For which other common illness would doctors be prescribing a treatment that merely works 15 per cent of the time?

OBESITY IS A COMPLEX DISEASE

It’s easy to play the obesity blame game and focus on a person’s lack of effort and self-control in improving their diet and sedentary lifestyle.

The truth is, many other factors contribute to obesity: Genetics, ethnicity, mental health, side effects from medications and even certain viruses. People who suffer from obesity have little to no control over some of these factors.

This old way of thinking has serious implications when obesity rates are on the rise in Singapore, especially among children and teens. In the period from 2019 to 2020, 10.5 per cent of Singapore residents aged 18 to 74 were obese.

Obesity is defined as a Body Mass Index (BMI) of 30 or higher. Asians get a lower threshold of 27.5 for high-risk BMI, given the higher risk of heart and kidney diseases and diabetes. Carrying excess weight also increases pressure on the joints, makes one feel more tired and increases the risk of surgical complications.

What people with obesity need is a comprehensive approach that addresses the root causes of their condition.

Purported quick fixes out there - from supplements and juice cleanses to beauty salon procedures - often take a short-term view to weight loss. A holistic long-term view would need to recognise unique needs and factors for individualised weight loss strategies, not mere superficial changes.

NEW DEVELOPMENTS IN MEDICAL TREATMENT

In this paradigm, exercise, nutrition, behavioural support and medication are not standalone solutions, but parts of a larger toolkit for more sustainable outcomes. Weight loss drugs can play a crucial role when carefully prescribed as part of a holistic strategy.

New drugs containing semaglutide have been viewed as “miracle drugs”. One study recorded an average of 14.9 per cent loss in body weight over 68 weeks, while another group studied consumed 24 per cent fewer calories after 12 weeks.

Newer drugs like Zepbound, which contain tirzepatide as the active ingredient, touted weight loss of 20 per cent or more in a clinical trial, putting them in the same realm as the far more invasive bariatric surgery.

In Singapore, the Health Sciences Authority (HSA) approved semaglutides under the brand names Ozempic and Rybelsus in 2021 for Type 2 diabetes and Wegovy in 2023 for chronic weight management.

What’s notable now is that for the first time in the history of obesity treatment, such medication not only helps patients lose weight and eat less, but also reduces the risk of dreaded complications like kidney and heart diseases and other chronic diseases.

Of course, these new medications are not without their downsides. Semaglutide has been reported to cause nausea, diarrhoea, constipation, headache and fatigue, among others. It also comes with warnings about an increased risk of pancreatitis and gallbladder problems, and even suicidal thoughts (although this has since been disproved).

STIGMA OF USING WEIGHT LOSS DRUGS

Nonetheless, there is still stigma around using medication for weight loss, anchored in the old idea that weight loss came through sheer willpower.

For decades, the famous weight loss company, WeightWatchers, sold its diet programmes with this narrative. Whose fault would it be if people didn’t stick to the programme? Now, even its CEO Sima Sistani has acknowledged that there is no shame for people for whom diet and exercise were not enough.

Cynics may remark that the company now charges for access to weight loss drug prescriptions, so perhaps it is precisely the breakdown of willpower that drives people to seek weight loss with the least possible effort.

But there’s no denying that this highlights just how much our understanding of obesity has changed. There will always be a burgeoning marketplace for weight loss solutions. The surge in demand for drugs will only spur more research and development and further improve our understanding.

With these weight loss medications, many individuals are now able to develop a far healthier relationship with food, as well as their self-esteem, something that has been out of reach when it was all about their lack of willpower.

WHAT CAN PEOPLE SUFFERING FROM OBESITY DO?

We need to take a balanced approach. Of course, watching one’s diet is better than uncontrolled eating, and light physical activity is better than staying seated all day.

There is limited effectiveness in undertaking medication, dieting or exercise in silo - in fact, managing obesity through dieting alone may have adverse effects. Research has shown that up to 25 per cent of total weight lost can come from the loss of muscle, bone and other fat-free tissue, which can result in a lowered metabolism and reduced strength and performance.

It is thus important to go with a personalised, holistic approach for weight loss managed by experts, so that side effects, both short- and long-term, can be addressed effectively and sustainably depending on one’s lifestyle.

Obesity may be on the rise in Singapore and globally, but so is our understanding of the illness and the options for treatment, giving us better control over it going forward.

Dr Kyle Tan is a co-founder and consultant at NOVI Health.