Weight Loss: What is New in 2022?

J. David Prologo Interventional Radiologist | Vascular & Interventional Radiology Johns Creek, Georgia

Dr. Prologo is a dual-board certified obesity medicine physician and interventional radiologist. He is an internationally recognized expert in the management of complex pain and the implementation of interventional weight loss. Dr. Prologo is the author of a critically acclaimed non-fiction narrative describing innovative... more

J. David Prologo, MD, FSIR, ABOM-D (www.drprologo.com) is a dual board-certified obesity medicine physician and interventional radiologist. He is the author of the highly acclaimed Catching Point Transformation: A 12-Week Weight Loss Strategy Based in Reality.

 

For more than fifty years we have held up the “calories-in, calories-out” dogma as the gold standard for weight loss. Meanwhile, the incidence of obesity has quadrupled. “You can’t argue with the math,” we would say, while individual success rates hover at 5% (and even most of them gain it back). The rapid global rise in persons with overweight or obese conditions has continued unfazed and uninterrupted by our best treatment options. The number of patients with these conditions has continued to multiply and overwhelm us, as we backpedal and throw antiquated “diets” at them.

Few would disagree that we needed something new. Even the patients themselves plead with us to understand that there is something happening with their bodies that hampers the success of our treatments. Is it my thyroid maybe, they ask? Genetics? Stress? The devil?! Although it may not be any of those things, it is something. And focusing on that is what is new for 2022.

Persons with overweight or obese conditions face a host of variables that block them from losing weight on their own: hunger hormone spikes, reactive metabolism decreases, unfavorable gut microbiomes, and adiposopathy, just to name a few. The identification and direct targeting of these biological resistances have revolutionized the modern approach to weight loss. We have changed our focus to mitigating these variables.

For example, consider the hunger hormone system. It's clear that hunger hormone levels increase with weight loss – and stay elevated. This translates to increased and sustained hunger in response to weight loss (a phenomenon that does not occur in our lean counterparts under the same conditions, by the way; more on that below). Moreover, those with excess body fat are resistant to the hormone that makes us feel full, called leptin. So, the first thing that happens on that fateful “day 1” of a calorie restriction diet for an overweight person is that the body floods the bloodstream and nervous system with a hormone that makes you insatiably hungry and directs you to seek food in the name of survival. And that is only the beginning.

Simultaneously, the body will drop its basal metabolic rate (the number of calories burned by the body just to stay alive throughout the day). This means when you kill yourself to cut 800 calories from your daily intake, your body offsets your efforts by decreasing the amount it burns on its own. It does this so you don’t starve to death. It perceives your calorie restriction as a potentially lethal event, so it slows and stores every single calorie it can – which clearly obstructs your effort to lose weight.

After reviewing just two of these body responses, we can see why everyone is frustrated and starving 10 days into every “diet.” We can start to see why these treatments don’t work. But that is not all. Often times overweight or obese patients have unfavorable gut microbiomes. They will literally absorb more calories from a given food than someone with a different set of gut bacteria. So, when we hear, “I could eat exactly the same thing as skinny Sandy over there and still gain weight,” we should believe it!

On top of all that, the disproportionate presence of fat cells in the human body creates a condition called adiposopathy, or “sick fat disease,” which serves as an obstacle to weight loss by producing hormones that cause dysregulated inflammation. This cascade leads to fatigue, worsened leptin resistance, dysthymia (depressive symptoms), and even outright metabolic disease – all of which is exaggerated in the face of a new calorie restriction exercise combination assault.

Knowing all of this has resulted in two important things. First, it has undercut the fat-shamers (and, in my opinion, obligated them to apologize). The identification of unique forces that emerge and block weight loss in individuals with overweight and obese conditions validates the claims of a group of people who have faced unrecognized challenges for a long time. The idea that patients who struggle with weight loss somehow lack the necessary mental fortitude to conquer their disease is essentially debunked. It turns out that “willpower” is not the issue here. It turns out, after all, that “mind over matter” is bulls#$%.

Second, it shifts the focus of researchers and caregivers toward something new. Something other than handing out the same plans and encouraging our patients to somehow “white knuckle” through. It gives all of us new targets for therapy. To illustrate, surgeries and procedures have been developed that decrease hunger hormone levels by removing or blocking the cells that produce them. These interventions consistently result in weight loss. Big weight loss. Hundreds of thousands of pounds or more by now, and even the reversal of associated diseases like diabetes and high blood pressure.

Importantly, these are not “willpower implantation” procedures. These are interventions that address the body’s resistance to weight loss. Other examples include a procedure performed at Emory University School of Medicine in Atlanta, GA, that uses a cold needle to freeze the nerve that carries the hunger signal from an empty stomach to the brain, thereby blocking hunger and easing calorie restriction for dieters. The FDA approved prescription medicine for weight loss in 2021, the mechanism of which is to increase feelings of fullness and decrease hunger – again directly targeting the body’s response to dieting.

What about outside of the formal medical setting? Same theme. Focus on the things that have blocked us in the past. Attenuate the body’s response to calorie restriction and new exercise so that we can change our lives in the long run. Consider the body’s reactive metabolism drop described above. These metabolic changes can be addressed by targeting one change at a time. While staying full, patients can increase their exercise capacity to critical points and block or even improve their otherwise dropping basal metabolic rates, thereby clearing yet another of these obstacles. Specifically, the American Heart Association (and many other authoritative bodies in this space) recommend being able to perform at least 500 Met-minutes per week of physical activity. A key turning point for those hoping to make a change with regard to weight loss is an exercise capacity of 210 Met-minutes, or the ability to perform moderate exercise, such as jogging without stopping, for 30 minutes in a single setting.

Pursuing this exercise capacity goal also does several other positive things for the otherwise would be diet-failer. It sparks a new momentum by altering food preferences toward healthy choices, arms the patient with the ability to impact weight loss through calorie burns, and protects them from heart disease, diabetes, and cancer. But how to get there?

The path to establishing said exercise capacity has also been defined, with a new focus on eliminating static programs. No one ever failed their fitness schedule or diet program because it was mathematically incorrect or not going to lead to weight loss in a vacuum, people quit because they succumb to overwhelming signals from the body in the name of survival. Changing from our old-fashioned bullheaded approach to physical activity to one that embraces recovery, individuality, biofeedback, and dietary supplementation blunts those counteractive survival signals and permits progressive change. Change that makes subsequent lifestyle changes easier – in what is called a kinetic sequence. It further leads to internal reorganization and body composition changes, which decrease the effects of adiposopathy!

Armed with more physiological information regarding obesity and its treatment than ever before, the future is bright for those seeking weight loss. A host of new targets have been defined that have heretofore existed in veritable invisibility – only being acknowledged by those who personally felt them. Now our eyes have been opened. We all understand the challenges, and we as medical professionals accept our responsibility to keep developing novel solutions to these complex problems, while simultaneously resisting all biases and blames that may materialize as a result of our shortcomings.