Principles of Treatment of Overweight

My approach to treating the overweight patient is based on these fundamental points:

1. About 40% of the tendency to gain excess fat is due to genetics. Body fat percentage clearly is a trait that usually runs in families.
2. About 10% of the tendency to gain excess fat is due to early feeding experiences and to childhood stress. This means that a high-carb diet in childhood, or excess stress during the first few years of life, creates hormonal set points that promote fat storage.
3. About 50% of the tendency to gain excess fat is due to current behaviors. This includes diet, exercise, and current stress.

The first two points (above) determine how easily a person will gain or lose weight. If genetics and early feeding experiences are strongly in the overweight direction, then the patient will have more inertia to push against as she loses weight, and the struggle against overweight probably will be a lifelong issue. This does not mean, however, that the struggle can’t be won—it can.

We can’t do anything about our inherited genetics. We can’t do anything about the way we were fed the first few years of life (although we can try to reduce carbs in the diet of our own children) But we can do something about current behaviors, the third point above. Fortunately, in every overweight patient I’ve treated, modification of current behaviors is sufficient to attain a healthy weight no matter how adverse the genetics or early childhood feeding and stress experiences. Now, here are more of my basic points of treatment, all applying to current behaviors:

1. All overweight individuals are overweight due to overeating carbohydrates. No one has a significant weight problem due to overeating protein. No one has a significant weight problem due to overeating fat. Everyone who is overweight is overeating potatoes, bread, sweets, chips, pasta, cereals, soft drinks, rice, beans, corn, oats, and similar starches and sugars. There are two reasons why carbs are the cause of overweight. First, carbs are the only food type that we crave in excess. Second, carbs raise our level of insulin—the hormone that increases fat storage by activating lipoprotein lipase.
2. Overeating carbs is largely due to the addictive, compulsive craving for carbohydrates. This is very similar to a smoking addiction. Like a smoking addiction, carb cravings are due to chemical changes in particular circuits of the brain. Carbs increase the levels of dopamine, serotonin and norepinephrine in these circuits, which leads to feelings of pleasure and relaxation.
3. The brain becomes habituated to the higher levels of these chemicals. As a result, these brain circuits generate strong discomfort when the levels of dopamine, serotonin, or norepinephrine fall. This discomfort will drive the person to get a “fix” of carbohydrates to raise the brain levels of these chemicals. This is the same biochemical craving mechanism involved in any addiction.
4. Stress increases levels of anxiety or depression (tension), and this will increase carb cravings.
5. Stress also increases the level of cortisol, a natural steroid, which then increases fat storage.
6. Lower amounts of muscle reduce your Resting Metabolic Rate (RMR), thus reducing the calories burned each day. Lower muscle also means you’ll need more insulin to control your blood sugar. So having less muscle makes it easier to gain weight and harder to lose weight. This is one reason we tend to get fatter with age—we lose muscle with age unless we do strength training.

So far, these principles have dealt with the causes of overweight. Now let’s list the principles of treatment that follow logically from these causes:

1. Overweight individuals must reduce their consumption of carbohydrates. This will reduce their insulin level, deactivate their lipoprotein lipase (the fat storage enzyme), and allow fat loss. We should lower carbohydrate consumption to the lowest reasonable level during the weight loss phase; we will then raise carbohydrate consumption a bit for permanent weight maintenance.
2. No one with a significant weight problem will be able to reduce carbohydrate consumption for more than a few weeks based on “willpower” alone. The chemical drive in the mid-brain that produces carb cravings is just too strong to resist long-term. As I described in an earlier chapter, using willpower to control carb cravings is like resisting a strong urge to scratch an itch or trying to hold your breath: you can do it for a while, but eventually the cravings will prevail.
3. Therefore, we must use medications to reduce the carb cravings. This is like eliminating the itch—then it’s easy not to scratch. We use medications that increase the brain’s levels of norepinephrine, serotonin, and dopamine. This gives the midbrain’s circuits what they crave without your having to eat carbs.
4. We also use medications to reduce the effects of stress so that your cortisol level is reduced. This reduces fat storage, too.
5. We use a combination of two medications to raise all three relevant brain chemicals: norepinephrine, serotonin, and dopamine. These medications are safe and non-addictive. There are virtually never any serious side effect problems. The medications can be continued as long as needed both to reduce weight and to maintain your new healthy weight.
6. When you attain your new healthy weight, we will slowly reduce the medications and carefully watch your weight. If you need the medications restarted occasionally—or even permanently—we will do that. For most individuals overweight is a lifelong disorder that will need management lifelong.
7. Weight loss will be faster, and weight maintenance will be easier, with more muscle on your body. The way to increase muscle is with strength training (weight-lifting type exercise) twice weekly, for about 30 minutes each session.
8. For most overweight persons, carb addiction will be a lifelong condition. She will never be cured of carb addiction; however, she can become a permanently “recovering” carb addict. She can learn to live a carb-sober life. This will be the way to eliminate overweight from her life.

These 17 principles are the essence of modern weight loss treatment. Basically, they emphasize that overweight is a chemical problem, that willpower alone will not overcome it, that medications help treat overweight successfully, and that lifelong carb sobriety is the way to eliminate overweight permanently.