Why the science of weight loss says you have to start by loving yourself

Ian Patton has lived with obesity most of his life. 

A few years ago, he was struggling. 

"I was dying from obesity. I was waking up and thinking I was not sure I'd wake up the next day." 

He's doing much better today, but he's not alone in his experience of living with obesity.

According to 2018 Statistics Canada figures, approximately 27 per cent of Canadian adults are obese and about 36 per cent are overweight.

Obesity has traditionally been defined as having a Body Mass Index (BMI) over 30, and overweight as having a BMI over 25. 

While BMI tables are still used as a broad guide, they often overlook factors like ethnicity and gender, making them ineffective on an individual level, said Dr. Sean Wharton, an internal medicine specialist and the medical director of Wharton Medical Clinic, which treats patients with obesity and diabetes.

Whether you need to lose weight is not about the number on the scale or your BMI, he added.

"You will need to lose weight if the fat cells that you've accumulated — the excess ones — are causing a medical condition like Type 2 diabetes," Wharton told Dr. Brian Goldman, host of The Dose and White Coat, Black Art. "If you just have weight that's a little higher than the rest of the population, but you've got great knees, your blood sugar is perfect and everything else is great, then you are perfect."

Diet, exercise aren't key to losing excess weight: doctor

Patton, who is the director of advocacy and public engagement for Obesity Canada, an advocacy and research organization, says losing weight is frustratingly hard and the health-care system often offers advice that is not evidence-based.

"I had doctors saying, 'Why don't you eat more salad and go for more walks,'" said Patton. "I have a PhD in kinesiology. I'm a registered exercise physiologist. I know more about diet than most. That knowledge won't help me lose weight."

Despite what you may have been told, the best science shows diet and exercise aren't the key to losing excess weight, said Wharton.

While exercise is "probably the most important thing that people can do for their overall health … [physical] activity does not have a significant impact on weight change," he said.

As for diet, Wharton said, pick whatever healthy diet works for you. The challenge is not picking a particular diet, "it's staying on it," he added, and that's where evidence-based weight management comes into play. 

Wharton said there are three pillars to losing weight: psychological, pharmacotherapy and surgical. However, he noted these strategies are aimed at people who fit his criteria for weight loss — people whose excess fat cells are causing a medical condition or have high BMIs — and are not for someone who just has a few pounds to lose. 

Psychological intervention critical first step, says doctor

Wharton said psychological intervention involves cognitive behavioural therapy to understand our behaviours — why we eat, and when we eat. 

Whether you're overweight or living with obesity, the starting point for weight loss is simple, said Wharton: You need to love yourself at whatever weight you are right now.

Wharton said most people start a weight management program with a goal weight in mind, thinking "I will feel better and love myself more when I get to that stage," but he said research shows this does not happen. 

"If you don't love yourself now at that weight of 315 pounds, or 350 pounds, or 400, then the chance of you loving yourself and taking care of yourself when you get to a lower weight is very, very low."

Certain drugs can help manage appetite, cravings

The brain is the primary organ that controls weight, said Wharton. Certain drugs work to tell the brain to manage cravings, and use the stored energy of extra fat cells rather than eating more.

There are two different kinds of drugs approved for use in Canada, according to Wharton: GLP-1 therapy, and a combination of anti-addiction and antidepressant drugs.

GLP-1 is a hormone in your body that impacts appetite. According to Wharton, people living with obesity don't have enough of this hormone to tell the brain to stop eating, so the GLP-1 therapy helps by decreasing appetite.

The second approach combines medication commonly used to manage addiction, with an antidepressant. It works to control both hunger and cravings. 

These drugs aren't for anyone looking to lose weight. In both cases, these drugs are approved in use for patients with a BMI of 30 or higher, or a BMI of 27 and above with the presence of at least one weight-related condition such Type 2 diabetes or hypertension. 

Bariatric surgery for some forms of obesity

The third pillar of effective weight loss for excess obesity is bariatric surgery, Wharton said.

People often think this surgery works by making the stomach smaller to limit how much people can eat. But according to Wharton, that's not how it works. 

"The rewiring of the GI [gastro-intestinal] tract allows hormones to flood to the brain to tell the brain: 'You are not hungry' … to change the way that we think about food — our cravings for food, our hunger — and allows the body to use the stored fat cells."

Wharton said bariatric surgery is for people on the more extreme end of weight with medical conditions, such as Type 2 diabetes.

Comparatively, he said, medications and the psychological therapy work well for "many, many people."

Bias and stigma 

There is still a great deal of bias in the medical profession toward people living with obesity, according to Wharton. 

"Medical professionals say things like … 'You're just not trying hard enough. You're not motivated. You don't have willpower. You should work harder,'" he offered as examples.

These messages are damaging and unhelpful, he said, and reflect the larger societal attitudes toward larger people. 

Patton agreed, and said the pandemic has only exacerbated the stigma over the past year. 

This is a tough time. Stop looking at the scale. Start trying to be as healthy as you can while being as happy as you can.- Ian Patton

"Anyone who has lived in a larger body has experienced some degree of bias … but COVID has increased the stigma against people living with obesity," he said.

"For example, when it first came out that living with obesity was correlated with more severe outcomes with COVID … we saw vile things published."

Patton said for anyone who wants to start losing weight, whether they've gained weight during the pandemic or have lived with obesity for a long time, his advice is to take it easy on yourself.

"This is a tough time. Stop looking at the scale. Start trying to be as healthy as you can while being as happy as you can."