I have been treating patients with weight problems in my medical practice for over thirty years. In addition, even before my medical training, I was trained in Nutrition Science and conducted nutrition research studies. Based on this background, I can give you reliable guidance to help you achieve healthy weight control goals. Unfortunately, much of the information currently being published about how to manage excessive body weight is unreliable, and some of it may even be detrimental to your health and wellbeing. This short summary will focus on what is most important for you to know, as well as strategies that are readily available to help you if you have a weight control problem.
Realistic goals are essential to your success
There are two things you must understand if you are to have long-lasting success. The first is that rapid weight loss strategies will cause almost everyone who tries them to eventually fail! This is because your body has powerful protective systems to protect you from continued, rapid weight loss. Excessively rapid weight loss causes malnutrition, and most people who lose weight too rapidly will find themselves eventually regaining everything they lost and more.
The second key understanding is that for almost everyone who is overweight, the tendency to gain too much body fat is a life-long problem! There are many strategies that will result in significant weight loss in the short term, but if you resume your previous eating patterns and lifestyle after they are finished, your weight will start increasing again. This means that long term success requires an approach that can comfortably become a part of your lifestyle.
Unfortunately, because of these factors, it is quite common to see people engage in strategies resulting in rapid weight loss, fail to continue them, and then gain even more weight than they lost. When this happens repeatedly, it has been called the “yo-yo” dieting syndrome. Short-term, rapid weight loss programs not only don’t work, if you repeatedly use them, they can even damage your health. They can also cause people to become quite discouraged.
You need to know what rate of weight loss is compatible with long term weight control goals. Several decades of treating people with weight control problems have given me guidelines to know the rate of weight loss that is sustainable. If someone is within about 50 pounds of their most healthy weight, they can usually only lose about 2 pounds a month if they are to keep it going until they reach their target. If they are higher than this to start, they can probably successfully lose 3 to 4 pounds per month and keep it going. Faster weight loss than this just doesn’t work over the long haul for 99% of those who try it.
Healthy food guidelines, simplified
For the most part, special diets, calorie counting, and popular food fads do not work well. Part of the reason is that they are often too difficult and too much work to be life-long food control strategies. Another part of the reason they fail is that they are usually not very satisfying. What is needed is a way of eating that you can continue for the rest of your life, that will help you lose weight at a reasonable rate, and that will support what your body needs for good health. Once you have a good plan, you must stick with it long enough to re-train yourself to enjoy healthy food and unlearn bad habits. The first thing I usually try is a few simple rules:
1. If you are not truly hungry — don’t eat.
2. If you are hungry, eat enough to keep yourself reasonably satisfied until your next meal.
3. Whether you eat meals or snacks, only eat healthy food.
It is the “only eat healthy food” that is the most difficult part of this for most people who struggle with weight gain, especially in the first few months of making these changes. Avoiding situations where unhealthy food choices are easily available may be very helpful with this transition. What follows is a set of directions that will move you toward good food choices. I will list the most important first, (based on my experience with what have been the most likely to undercut the efforts of the people I treat):
1. Avoid sugars in drinks such as sweet tea, sodas and fruit juice (one glass can increase your appetite for more than 2 days).
2. Avoid most red meats and other foods high in animal fat. Substitute fish, fowl or lean cuts of meat.
3. Substitute whole grain foods in place of refined grains.
4. Include plenty of fruit and vegetables.
5. Avoid high sugar and high fat snacks.
I say move toward these the food choices since it may take several months or more to re-train your taste buds to be satisfied with a healthier way of eating. If you have very unhealthy food habits, trying to change everything all at once rarely works. Focus on the most important changes first, then added other improvements later.
It is important to be aware that not only will these food choices help control body weight, adopting them will also help prevent heart attacks, strokes, diabetes, dementia, and a long list of other chronic medical problems. This is still true even if a healthier way of eating fails to control body weight.
Exercise will not counteract poor food choices
There is no doubt that a sedentary lifestyle promotes weight gain. Since a certain amount of physical activity is needed for your appetite to function properly in controlling your body fat stores, a sedentary lifestyle, by itself, can be a cause of overweight.
Unfortunately, exercise does not burn as many calories as most people think. This means that even a very vigorous exercise program will not allow you to continue making poor food choices and still control your weight. Exercise is important, but you must also pay careful attention to your food choices.
Weight loss medications can sometimes be very helpful, if used appropriately
Weight loss medications can easily be a waste of time and money if you do not continue to follow reasonable guidelines for diet and exercise as you begin to use them. Furthermore, even a medication regimen that is working well will be useless for long term weight control if not continued for long enough. This may mean several years or even longer. It takes the expertise and assistance of a clinician with a lot of experience with these medications to use them well.
Recently, new medications have become available that are very effective in treating diabetes while also being very helpful in lowering excessive body weight (this class of medications is called GLP-1 agonists). Some of these have now also been approved for use by people without diabetes. While they are very effective and very safe, their cost can be quite high. Keep in mind that if you want to try one of these, you will likely need to continue their use long term to maintain their benefit. They probably help counteract an inherited metabolic problem that will re-assert itself once the medication is stopped.
What causes weight control problems in the first place?
Most people assume that if someone is overweight, it is because of a lack of self-control. Based on my experience of having treated many thousands of patients with this problem, I know that it is relatively rare that being overweight is only due to a lack of concern and a lack of effort to control the problem. For many people struggling with their weight, both eliminating the medical causes of overweight and following healthy food selection and exercise recommendations are not enough to stop their tendency toward continued weight gain. If this was all there was to it, hardly anyone would be overweight.
To give at least a partial answer to the question of what causes most weight control problems, I will provide a summary of the different outcomes my patients have had over the last three decades or so under my care. This list will include an approximation of how many fall into each category. Please note that only those patients that followed up with me long enough to effectively use currently effective treatment strategies are included (but this includes just about everyone I have treated).:
About 5% — Weight control problems that were due to medical problems like hypothyroidism or weight gain as a side effect of a chronic medication. Once the problem was eliminated, the weight problem completely resolved.
About 5% — Weight gain that was found to be due to a previously unrecognized or poorly controlled depression. Once the depression was successfully treated, their weight returned to normal.
About 12% — Patients who just needed knowledgeable guidance about diet and exercise. These individuals lost their excessive body fat and kept it off by following good advice and changing poor food habits.
About 35% — Patients for whom diet and exercise alone were not effective in controlling their body weight, but who have been very successful after one or more weight loss medications were added to their treatment. These medications usually have needed to be continued to keep the problem from returning.
The remainder (about 40%) — People who have done everything they can with a well-designed diet and exercise approach, and for whom none of the available weight control medications have been effective in stopping weight gain. While their overweight problem was not completely controlled, almost all have been gaining significantly less weight than if they were not being treated.
When I consider this list, it is obvious to me that there are other problems causing so many people to struggle with their weight, even while they are carefully following a well-designed food plan and exercise routine. One clue to what else might explain it is that many people overeat when under stress. Another clue is that many medical problems like high blood pressure, diabetes and abnormal cholesterol often cluster together in the same individuals who also struggle with their weight. Looking carefully at the research in this area suggests that there may be one or more causal factors resulting in all these problems. That is, it is likely that the same factors that cause weight control problems are also responsible for chronic medical conditions like hypertension and diabetes.
Although the evidence is limited since there are relatively few research studies evaluating treatments based on these insights, certain new treatment strategies show promise in helping the large number of people for whom food modifications and adequate exercise are not enough to control their body weight. Some promising strategies are discussed in an article I call “Simple Self-Healing Strategies.” You might benefit from trying one of more of these strategies, especially if you tend to overeat when you feel stressed.
For those who are very overweight and who have tried the recommendations I have discussed here without success, a surgical weight loss program can be a reasonable option. But you should know it will permanently eliminate your ability to eat a normal meal. It will also require life-long medical follow-up to be both safe and effective. It should be only for those suffering serious medical complications from their excessive body weight and who have truly given less drastic approaches to weight control every chance to be effective.
This has been a relatively brief introduction to a very complex medical problem. If you are very interested in this topic and would like a much more in-depth education about this topic, the following link will take you to a 55 page booklet I wrote a few years back: Weight Control Handbook
Revised, 6/16/24, C. Gebhardt, MD
Science and Spirit 