It’s so easy! Just eat less and exercise more!
Tired of hearing people say that? So am I.
While it is true that putting on weight and losing weight all boils down to how many calories you consume versus how many calories you burn, it is however not true to say that obesity is all due to a poor lifestyle and lack of willpower.
Many of the patients I have seen like to blame our modern world for the obesity epidemic. Namely the availability and convenience of unhealthy processed calorie rich food and office jobs promoting a sedentary lifestyle. Although these are certainly contributing factors, they alone cannot explain why we put on weight.
Obesity is a complex multi-factorial disease like Diabetes. And just like Diabetes, people who suffer from Obesity need the support of family, friends and the medical community to manage it.
In Singapore, 30% of us are overweight and 10% of us are obese.
So what exactly is the cause of obesity?
There is no one single cause of obesity. Obesity is a complex and multi-factorial problem. Very recently the World Health Organisation came up with a ROOTS of Obesity Fact Sheet. In it, it lists 9 factors that can all contribute to obesity in an individual. These are:
- Biology – out bodies are designed to store energy to protect itself from starvation. More on this later.
- Food – as mentioned, we have easy access to highly processed high caloric foods.
- Genetic Risks – genes account for 40% to 70% of risk of developing obesity. Studies who the majority of Identical twins reared apart in vastly different diet environments end up being the same weight.
- Healthcare Access – not being able to see a Doctor or not wanting to see a Doctor leads to obesity.
- Life Events – this includes illnesses and medication that can cause weight gain.
- Marketing – heavy marketing of foodstuff promotes obesity.
- Mental Health – various mental health issues as well as medications to treat them contribute to obesity.
- Sleep – lack of sleep influences the hormonal balance and can lead to weight gain.
- Stigma – when people with obesity are stigmatized as lazy or weak willed they are less willing to seek help for their obesity disease
How do I know if I am overweight or obese?
Although, not perfect, many healthcare professionals still rely on the Body Mass Index (BMI) to determine if a patient is normal weight, overweight or obese.
There are many online calculators available to calculate your BMI. You just need to know your height and weight.
Use this table to interpret what your BMI means:
BMI Classification for Asians
BMI > 23.0
Overweight
BMI > 27.5
Class I Obesity
BMI > 32.5
Class II Obesity
BMI > 37.5
Class III Obesity
Another useful measurement if your waist circumference. Remember the waist is the part of your tummy that is midway between the top of your hips and the bottom of your ribs. To make it easy, take the circumference at the level of your belly button. Remember your waist circumference is not your pants size. Many of us wear our pants below the waist.
For Asian Men, you are at an increased risk if your Waist Circumference is > 90cm.
For Asian Women, you are at an increased risk if your Waist Circumference is > 80cm.
So I’m a bit big. So what?
Carrying too much weight (or to be more accurate carrying too much body fat) increases the risk of developing many health problems like Diabetes and High Blood Pressure. Obesity can also lead to biomechanical problems like painful knees.
Obesity is also a pro-inflammatory state. As more fat is stored in fat cells, out immune system starts to react against it causing inflammation. Chronic inflammation in the body is related to the development of multiple diseases such as heart disease, strokes and even cancer,
Aside from increasing the risk of developing other illnesses, obesity itself increases the risk of death. In a giant study called the Global BMI Mortality Collaboration, patients with Class III Obesity are almost 3x more likely to die from any cause compared to someone of normal weight.
Wow! Do I really need to achieve a BMI of 23?
In the long run ideally yes. But start with setting an easy achievable target for yourself. Multiple studies have shown that a weight loss of just 5% to 10% of your current body weight will already lead to significant health improvement and reduced risk of disease. You will also likely feel much better levels of energy and alertness.
Why is it so difficult to lose weight and keep it off?
Our body is an extremely efficient machine. We are designed to consume and store energy very quickly and use energy very slowly. This makes sense for survival in a world where we do not know when our next meal will be.
So when we increase our energy expenditure and decrease our energy intake, our body fights back. Our body does not know that we are trying to lose weight. All it knows is that it is losing its energy stores and if this goes on, its survival will be at risk.
So what it does is increase the production of hormones that make us hungry and decrease hormones that make us feel full. It also reduces our base metabolic rate and unconscious movements so that we are burning as few calories as we can every day. This is the body’s way of defending its “Weight Set Point” which is the weight that the body naturally wants to go back to. Very much like how the body defends its temperature set point adnd blood pressure set point.
In fact, even after we have gone back to the original Weight Set Point, the hunger hormones continue to remain higher than usual and the satiety hormones continue to remain low. This causes us to put on even more weight than we started out at. From a survival stand point this makes complete sense. Your body is thinking “phew I managed to survive that period of starvation. I better store up more in case it happens again.”
So that means there is no hope of me ever losing weight?
Of course not! The simple fact remains that if we limit the amount of calories we take in every day, our body will start to burn up our fat stores and we will lose weight. The only thing we have to figure out is how to hack our hormones.
The first thing you need to realize is that there is no quick fix. Forget about all those advertisements you have seen on quick easy effortless weight loss.
The second thing you need to know is that this will be a lifelong effort. In other words, do not get so hung up on days where you eat a bit more because it’s your birthday or you are celebrating a promotion. These are not “cheat days”. These are deviation days. Because your end goal did not change. You just took a very minor detour to get there.
Thirdly, go see your Doctor or a weight management healthcare professional. You need someone to help you set goals and targets, plan your meals and your exercise. You may even benefit from medicines. These are not as scary as they sound and does not mean you are a weak willed person. We will talk more about this later.
Eat less or exercise more?
It is honestly extremely difficult to exercise your way into weight loss. Let’s look at the numbers. Let’s assume we consume an excess of 500 kcal a day. Which is not uncommon in urban societies according to some studies. To achieve weight loss we would want to reach a net negative of 500 kcal per day. If the diet stays the same, it would mean we have to burn 1000 kcal a day with exercise. For a 70kg male this would translate into an hour to an hour and a half of intense exercise every day. While not unachievable, it is very challenging.
Not only that, as you lose weight, your base metabolic rate drops. So in order to sustain a net loss of 500 kcal per day, you would need to burn even more calories. Click here to calculate your base metabolic rate.
Eating less is a very straight forward way to achieve a net negative daily caloric balance. An excess caloric intake of just 3% a day leads to 2kg weight gain in a year.
Of course what we eat is equally important. We want nutrition without excess calories. And most of the calories we consume should not come from carbohydrates. This will push the body to using fats stored inside cells as energy. Resulting in a decrease in adipose (fat) in the body. Remember that negative health effects from obesity is caused by excess adiposity (fat) and not excess weight per se.
However, if weight loss is achieved just via caloric restriction, we will not get all the other benefits of exercise such as better muscle strength, better balance and better heart and lung fitness. All of which are extremely important to leading a healthy life.
But eating less is so hard to do!
Yes it is. Again this is because our bodies are designed to make us take in and store calories. Getting into a detailed diet discussion here is obviously not possible. But there are 2 principles you should bear in mind:
- Eat for nutrition and limit calories
- Limit your carbohydrate intake
Energy Focused Diet Intervention
Energy Focused diets focus on counting calories. A net negative of 500 to 750 calories a day achieves a weight loss of 500g to 1kg per week.
Remember that as you lose weight, your body undergoes adaptive mechanisms like lowering its basal metabolic rate. Therefore, maintaining the same calorie intake daily will eventually lead to slower weight loss eventually stopping at a stable weight.
There are many Apps out there that help you track your caloric intake and output. Personally I use My Fitness Pal. This is not an endorsement of the App. Feel free to use any App you find useful.
A particular type of Energy Focused diet has become extremely popular and that is Intermittent Fasting (IF). Fans of IF find it easy to follow. There are also different types of IF like fasting for 16 hours then eating for 8 (16:8) or fasting for 2 days a week and eating for 5 (5:2).
Studies have shown that IF works for weight loss but is no better than other diets. However, there have only few studies involving a small number of subjects and we need more data.
Macro Nutrient Focused Diet Intervention
Macro-Nutrient Diets focus on where we get our calories from. The most popular Macro-Nutrient diet would be the so called “Keto Diet”. Keto diets limit calories from carbohydrates to as little as 5% of total calories. Most calories consumed are from fat and enough protein is consumed to maintain lean muscle mass.
One common side effect of the Keto Diet is the so called “Keto Flu”. This happens as the body changes from using sugar stored in the liver as an energy source to fats stored in the cells. Keto Flu symptoms include light-headedness, fatigue, headaches, nausea and constipation.
Again, in studies the Keto Diet is found to work but no better for weight loss compared to other diets.
It is however particularly good for people with Diabetes and results in improvement in sugar control and cholesterol and triglyceride levels.
Also, as the body switches over to using fats for energy (ketones), patients on this diet have a better control of hunger. In fact, they do not feel as hungry.
Dietary Pattern Focused Diet Intervention
The Mediterranean Diet emphasizes the intake of fresh vegetables, fresh fruits, legumes, nuts, whole grains and olive oil. With fish and poultry. Low intake of red meat. And here’s the good part – a moderate consumption of wine.
While each type of diet has their fans, the important thing is to find a diet that suits you and a diet that you can maintain.
Many people end up using a combination of focuses for their diet. For example limiting calories at the same time limiting carbohydrates.
Seeing a weight loss professional to figure out a diet plan is certainly worth your time
Exercise
As the saying goes “you cannot run your way out of a bad diet.” Exercise alone does not achieve weight loss. The now famous 10,000 steps per day only results in a 1% to 1.5% weight loss at 3 to 6 months. However, exercise leads to many other health benefits. And exercise combined with diet interventions lead to a greater amount of weight loss compared to diet alone.
So how much exercise should you do?
In a nutshell:
- 150 mins per week of mild to moderate intensity physical activity
- 2 days a week involving resistance training
Physical activity includes any kind of physical activity like mopping the floor or cleaning the car. It does not necessarily have to involve changing into your sports shoes and exercise gear and running in the park.
Resistance training can also be easily achieved by using your body weight. It does not have to be going to the gym and throwing dumbbells around. A simple resistance exercise to do is the sit-to-stand. While seated on your chair, cross your arms across the front of your chest. With both feet flat on the ground, stand up. Then sit down again. Do this for a minute.
The other very important part about physical activity is to avoid a sedentary lifestyle. Yes you can be exercising hard yet leading a sedentary lifestyle. In other words, you spend most of your day sitting at a desk. Make it a point to get up and take a walk around or do some simple exercises at your desk.
To start light to moderate intensity exercise, most people do not need to see a Doctor to get medical clearance. If you are not sure, click here to do the PAR Q + questionnaire. It is a simple screening tool to determine safety to exercise.
There are also great resources like Lumi Health (you need an Apple Watch for this) and ActiveSG that can get you active.
Or see your health professional to prescribe exercise for you.
What about weight loss medication?
Sometimes we just need a little help. Nobody thinks twice about taking medicine for diabetes yet many judge patients who take medicines for weight loss. Thinking that it is a failure of willpower. There is actually less stigma to turn to “natural” or over-the-counter medications even though these can be even more dangerous.
Always consult your Doctor before starting any weight loss medicines. Off the shelf weight loss pills may contain harmful substances that can really destroy your health and even cause death.
In Singapore, weight loss medicines are recommended if your BMI is above 30 kg/m2 or if you BMI is above 27 kg/m2 and you suffer from at least one obesity related health complication. Of course these are just guidelines and your Doctor will be the best person to advise you if you will benefit from weight loss medication or not.
There are 3 types of medicine approved to treat Obesity in Singapore:
Xenical – Orlistat
This medicine works by preventing the intestines from digesting and absorbing fat and oil. So any fat and oil that is consumed passes straight through the digestive tract without being absorbed. This reduces the total calories absorbed by the body.
The good thing about it is that this medicine is not absorbed into the bloodstream. It stays in the intestines and does its job there. In other words, it does not affect any of the other organ systems.
However, because the oil is not absorbed and passes out, this can lead to leakage of oil and potentially very awkward social situations. Not to mention soiled clothes and bed sheets.
It is taken 3 times a day (before each meal).
In studies conducted in people who took Xenical for 1 year (at the same time receiving nutritional counselling on a reduced calorie diet), about 50% loss at least 5% of their bodyweight and about 20% loss 10% of their bodyweight. The same patients also saw improvements in their cholesterol levels, blood sugar levels, blood pressure and also a reduction in their waist circumference. Some of these studies were extended to 4 years showing how safe Xenical is for long term use.
Because some Vitamins (namely Vitamin A, D, E) are only soluble in oil, it is recommended that people who are on Xenical take a multi-vitamin supplement at least 2 hours before or after taking Xenical.
Duromine, Panbesy - Phentermines
Both Duromine and Panbesy fall under the same class of medicines known as Phentermines. They work by increasing signals in the brain to reduce appetite.
The good thing with these medicines is that they are extremely effective in the short term. One study found a decrease of 10% of bodyweight in as short as 14 weeks.
However, this class of medications also come with a number of side effects including fast heart rate, high blood pressure, tremors, irritability, insomnia and dry mouth. Therefore not everyone can take it and Doctors are usually very careful when prescribing it.
The other problem with these medicines is that they can lose their effect rather rapidly. In Singapore, they are only recommended to be taken for 3 to 6 months.
Saxenda – GLP-1
This medicine works by increasing the satiety hormones. And thereby reducing hunger, appetite and increasing satiety.
Click here for our detailed article on GLP-1 Medications.
They are extremely effective. In 1 year, 2/3 of patients on Saxenda will lose at least 5% of their bodyweight and 1/3 of patients will lose at least 10% of their bodyweight. Some studies have been prolonged to 3 years of continuous use showing how safe these medicines are.
Aside from helping you lose weight, studies have shown that these medicines reduce waist circumference and reduce blood pressure. It can also delay the onset of Diabetes and even help people who are pre-diabetic go back to normal.
The most common side effect of this medicine is nausea. To overcome this, Doctors usually start their patients at a very low dose and slowly increase the dose over a month or more.
The other potential barrier is that this medicine is given as a daily subcutaneous injection much like insulin. Although this really shouldn’t be a barrier and all my patients find it convenient and painless.
Long Term Monitoring - Monitor Monitor Monitor
Losing weight is the first step. However, remember that this is a marathon and not a sprint. You will have to constantly keep your eye on the ball.
You should also always keep an eye on your weight. This does not mean you need to stand on the scale very day. Just once a week will do. Use the Traffic Light method to know when to take action.
Green – you have put back on 10% of the weight you loss. It’s OK. Just keep an eye on those calories.
Yellow – you have put back on 25% of the weight you loss. It’s time for another visit to your health care professional. You need to get back on that horse before it bolts.
Red – you have put back on 50% of the weigh you loss. A visit to your health care professional is urgent. You will likely need to get back on a treatment program.
Always be aware of your caloric balance. You do not need to count every calories but you should have a rough idea. Keep accessing that App you have to monitor your caloric intake.
So what now?
Step 1: Step on a scale. Take your weight and calculate your BMI. You are going to lose 5% of your current bodyweight in the next 3 months. Take your weight once a week.
Step 2: Download an App to monitor your calories. Calculate your Base Metabolic Rate. Aim to eat at least 500 kcal that your BMR. Eat more fresh fruits and vegetables. Eat less carbohydrates and processed food.
Step 3: Get the Lumi Health App or go onto the ActiveSG website. Plan to get 150 minutes of physical activity a week. Get off your chair at the office once an hour and take a walk around.
Step 4: See your health care professional. Check with him/her your diet and exercise plan. Ask if weight loss medicines can benefit you.
Good luck and look forward to seeing a healthier you!
Any questions or comments? Please put them in the comments section below.