Failing weight loss resolutions have nothing to do with willpower

Almost half of all New Year’s resolutions are to lose weight through diet and exercise. Weight and willpower are inextricably linked in our society. We’ve been taught that if you try hard enough you will lose weight, and if you can’t shed the pounds it’s your own fault or you have not tried hard enough.

January is often the most challenging month for individuals that struggle with their weight. It’s easy for negative thoughts to come up if you can’t keep a resolution and most resolutions are considered failures by the end of January. To understand why this may be, it is important to understand the role that biology plays in our weight, and how we need to think about weight care differently.

The science of obesity medicine

In 1994 scientists discovered leptin and it transformed how the medical community thinks about obesity. Leptin is a hormone made in our fat cells that signals fullness to our brain and helps regulate our body weight. This is just one of several hormones and neurotransmitters that regulate body weight that may not be working normally due to genetics, an environmental influence, or more likely a combination of those.

People who gain weight easily can have abnormalities in weight regulating pathways that make maintaining a healthy fat mass almost impossible, despite healthy diet and exercise. We use “fat mass” and not body weight, because people can be healthy at several weights! It is a high fat mass that is correlated with many diseases such as diabetes, high blood pressure, heart disease, and cancer. One example of a hormonal pathway that can misfire is related to insulin and carbohydrate metabolism. Some people are insulin resistant. They make a high level of insulin in response to eating carbohydrates which promotes fat storage even if calorie consumption is not very high.

The discovery of these hormones has led scientists and physicians to learn that weight gain and obesity are caused by biological factors. Obesity medicine physicians focus on science which helps to remove blame from patients and to look at interventions beyond diet and exercise that can help people maintain a healthy fat mass and overall body weight for them. This often includes medicines that can assist with weight loss that may act on one or several of the biochemical pathways that may not be working properly.

Obstacles we must overcome

The first wave of anti-obesity medicines (AOMs) in the US included Fen-Phen and Meridia. Both were taken off the market for safety concerns which led to a perception that medication is a dangerous and risky shortcut to weight loss.

Since then a new set of medicines have been approved and undergone very rigorous safety and efficacy trials, yet there are only 5 medicines approved for long-term use for obesity treatment: Orlistat, Qsymia, Contrave, Saxenda, and Wegovy. History and stigma have led to skepticism about AOMs and these medicines are highly scrutinized despite proven safety and efficacy.

Drug costs are high and insurance coverage remains poor for most of the listed medicines. Obesity medicine specialists often prescribe generic components of the FDA approved medicines to expand access to medicine for their patients. While it’s technically an “off label” use, it does not mean that medicines are not safe or tested. It simply means the medication is not branded for weight loss but can still deliver this result. In addition, obesity medicine physicians might prescribe off-label to more closely match dosing to an individual’s particular need and tolerance for medicine.

A path forward for true progress

Both private and public sectors must prioritize making drugs more affordable, expanding education of obesity medicine to more healthcare providers, incentivizing insurance plans to accept a larger range of AOMs, and supporting drug development.

Progress also means evolving mainstream weight loss narratives that are outdated. The medical community and society overall still fail to recognize biology in its narratives around weight loss, which must change. Awareness and acceptance will be important steps in getting more Americans to seek medical treatment for obesity. We must fight against stigmas that lead to embarrassment or shame. The covid pandemic highlighted how patients with obesity may suffer more severe consequences partially due to their avoidance of seeking healthcare in addition to several biologic factors that lead to more severe disease. Stigmatizing access to weight care can further exacerbate existing challenges.

My hope is that in the coming years, we’ll see fewer stories that link weight loss and resolutions, and more stories about lasting results from comprehensive care plans that are rooted in science.