What should you do if you have tried everything to lose weight and still have excess pounds (or kilograms) that you need or want to lose?
updated September 26, 2022
Consult your physician
If you haven’t already, talk to your doctor. Your doctor can evaluate your weight in the context of your total health. Perhaps you have medical conditions or medications that promote weight gain or make weight loss more difficult. You may need to address those before any weight loss plan will be successful.
Beyond that, you and your doctor might then consider weight loss medications. In general, they can be helpful in the short run which may get you started with sustained weight loss, but in general none of them have proven as successful and doctors and patients would like. This post describes what’s available now.
How to lose weight when nothing else has worked.
In helping people lose weight, there is a significant gap that needs to be closed. When diet/exercise fails, we need something less invasive before resorting to surgery with its significant risks and complications. One option is prescription medication.
This information is current as of the publication date; it is general medical information that helps doctors and patients make decisions about what is right for them. Medical recommendations and practice change as we learn new things. Discuss with your physician or appropriate healthcare provider.
Options beyond lifestyle alone
So who should consider advanced weight loss options? Anyone whose weight is excessive enough to be a health problem. In general this is considered to be those with
- a BMI, body mass index, of 40 or greater.
- a BMI of 30- 35 and certain medical conditions especially type 2 diabetes, heart disease, and sleep apnea
Calculate your BMI here.
According to the American Society for Metabolic and Bariatric Surgery, 250,000 metabolic surgeries were perfomed in the United States in 2019. The term metabolic surgery is now preferred because of the metabolic effects of surgical procedures beyond weight loss.
Metabolic benefits of weight loss
Although these can be true even for people with lower BMI , when those with BMI 30+ lose weight, they can experience
- improved blood glucose control in diabetes
- lower cholesterol
- lower blood pressure
- less severe or even resolved sleep apnea
- improved bladder (urinary)control
- relief from back and joint pain
- lower risk of many types of cancer
- less gastroesophageal reflux-heartburn
- and possibly lower risk of severe disease from SARS-CoV-2 virus (COVID-19)
Weight-loss Devices
The FDA regulates four devices intended for weight loss in certain adult patients age 18 and older.
Gastric Band –
bands are placed around the top portion of the stomach leaving only a small portion available for food.
Lap-Band Adjustable Gastric Banding System
Electrical Stimulation Systems –
electrical stimulator is placed in the abdomen to block nerve activity between the brain and stomach.
The Maestro Rechargeable System is implanted under the skin; an intermittent pulse generator delivers an electrical signal to the vagus nerve in the abdomen. The vagus nerve controls stomach action; when slowed down, one feels full sooner and theoretically will eat less. However, the company has not marketed it since 2018.
Gastric Balloon Systems
(This section updated 12/06/2020 with data from JAMA, 12/01/2020)
These inflatable balloons are placed in the stomach to take up space and delay gastric emptying. Estimates place these at 2% of all bariatric procedures. These systems are FDA approved for those with a BMI of 30-40 who have not lost weight with diet and exercise and who participate in a multidisciplinary weight loss program.
The ReShape Integrated Dual Balloon System was approved by the U.S. Food and Drug Administration in July 2015. Apollo Endosurgery purchased it in 2018 and replaced it with their existing product the Orbera Gastric Balloon, which is fluid-filled. Another system, Obalon,air-filled, is also approved.
The company claims patients with Orbera experience three times more weight loss than diet & exercise alone and are provided with the right tools and resources to successfully learn to keep it off.
The devices are placed into the stomach by going through the mouth and down through the esophagus with a tube called an endoscope. It takes about 30 minutes and requires mild sedation, not general anesthesia.
Once in the stomach the “balloons” are inflated; by taking up space in the stomach it can trigger a feeling of fullness.They are both temporary and must be removed within 6 months.
Mild to moderate adverse events are frequent; these can be nausea, vomiting, and pain.
In a Clinical Update, JAMA authors wrote that given the uncertainty of the long term safety, these devices should be used with caution, and not used when bariatric surgery is feasible.
The Allurion intragastric balloon (not yet approved by the FDA) does not require surgery and is highly effective in causing weight loss, according to a report in Family Practice News, February 2022.
Unlike other balloons, The Allurion gastric balloon is compressed into a small capsule connected to a thin catheter tube, then is swallowed; then it is inflated with 550 ml ( 18 ounces) of liquid to create a feeling of fulness and control hunger. After 4 months the balloon empties through a valve thatn opens spontaneously, the the balloon passes out in the stool.
As with any type of balloon device, “placement should only be attempted by clinicians with expertise in bariatric endoscopy.”
Gastric Emptying Systems
a tube is inserted between the stomach and outside of abdomen to drain food after eating
This device is called AspireAssist. This is a tube inserted into the stomach, from which a portion of the stomach contents can be “aspirated” (sucked out) after eating. The company claims patients lost 3 times more weight than those who received only diet and exercise counseling. The most successful patients lost over 100 pounds in the first year.
People lose weight with these devices largely due to the intensive counseling and support they received along with use of the device.
I encourage you to follow the links to learn more about each device.
Bariatric surgery
Two procedures comprise the majority of operations done to help people lose significant amounts of weight.
Sleeve Gastrectomy
In this procedure, a surgeon trained in bariatric procedures removes a large portion of the stomach, creating a long narrow tube.
The new, smaller stomach is about the size of a banana. It limits the amount of food you can eat by making you feel full after eating small amounts of food.
Gastric bypass
There are 2 steps during gastric bypass surgery:
In the first step the surgeon uses staples to divide the stomach into a small upper section and a larger bottom section. The top section, about the size of a walnut (called the pouch)will receive the food one eats. It holds only about 1 ounce (oz) or 28 grams (g) of food, causing one to eat much less.
The second step is the bypass. The surgeon connects a small part of the small intestine (the jejunum) to a small hole in your pouch. The food will now travel from the pouch into this new opening and into the small intestine. As a result, the body will absorb fewer calories.
Thus weight loss occurs from eating less and absorbing less food.
A success story
After gaining weight with her pregnancies, one woman , J.T. ,successfully lost weight with gastric bypass surgery.
I gained over 100 lb after my pregnancies. When my family doctor diagnosed me as borderline diabetic with high cholesterol, I panicked. Discouraged after failing numerous diets, I felt hopeful when I read about gastric bypass.
Learn about the lifestyle changes she made at this article from American Family Physician journal.
watercress words by Dr Aletha 
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