Why is it so hard for some people to lose weight?

Is there any way to fix the appetite dysregulation?

There are a variety of drugs that work in the hypothalamus to regulate appetite signals. For those with appetite dysregulation where hunger signals do not match what their body actually needs, these drugs can make it easier to eat less and lose weight.

Several drugs have been approved by the FDA for the treatment of obesity. Some of these are similar to drugs approved for the treatment of other conditions, such as type 2 diabetes, but have also been shown to be effective in treating obesity in clinical studies. (The two conditions often occur together.)

There has been a lot of buzz lately about a type 2 diabetes drug called semaglutide, which appears to be even more effective at weight loss than some of the drugs approved for treating obesity.

In the most recent study, participants received intensive behavioral counseling in addition to a weekly injection of semaglutide or a placebo. Those who received the behavioral counseling and a placebo managed to lose an average of 5% of their body weight … which is no small feat. However, those who combined intense behavior change with the medication lost over 15% on average.


Disclosure: In addition to his work as a clinician and at the clinical teaching faculty at Rutgers Medical School, Dr. Smolarz also serves as the medical director of Novo Nordisk, the company that developed semaglutide.

Why are these drugs so little used?

Given the prevalence of obesity and the enormous cost to individuals and society, one might think that these drugs would become more widespread.

If a person develops high blood pressure, high cholesterol, or high blood sugar levels, their doctor will likely suggest changing their diet and doing more exercise. And for some people, a change in lifestyle is enough to solve the problem. But for others, often those with a genetic predisposition, even the most careful diet and lifestyle efforts cannot do anything. At this point, the doctor will likely prescribe medication to help modulate any aspect of your metabolism that is out of whack.

When a person is excessively weight, their doctor (if they even mention it) will usually suggest eating less and getting more exercise. But if they can’t lose weight, medication is rarely discussed.

As pharmacist and obesity advocate Ted Kyle points out, 88% of people with type 2 diabetes are prescribed medication to control their blood sugar. Yet only 3% of obesity patients are prescribed anti-obesity drugs. (And that has doubled in the past decade.)

I have Dr. Smolarz asked why he thinks that.

“I attended allopathic medical school and a regular internist residency program. I did a mainstream endocrinology scholarship. What I call essential obesity was not in any curriculum. This dysregulation of appetite has not been taught.

“Obesity is the most common non-communicable disease on the planet. And we are learning more about bioterrorism and the use of potassium iodide than the use of drugs in this regard.”

Of course, not everyone who needs to lose weight needs an anti-obesity drug. Dr. Smolarz describes how he assesses patients seeking treatment for obesity.

“You want to look for secondary causes of extra weight first. Are there other drugs the person is taking that promote weight gain?

“There are also underlying medical conditions that could be causing this. Underactive thyroid can contribute to weight gain and be a cause of your inability to lose weight. This is something we would be looking for. Is that person an emotional eater, maybe or a traumatic eater? “Maybe it’s a sleep problem.”

In addition to treating any underlying drug conditions that may be contributing to the problem, the first line of treatment is still changing diet, increasing physical activity, and addressing behaviors that can lead to overeating. But treatment doesn’t always end there.

Dr. Smolarz:

“There isn’t a blood test that tells me you have an appetite signaling problem. I wish there was such a thing. You cross things off the list and then say, well, it is not, it is not. I’ll leave that. And so we’re approaching it.

“The first part of treatment is to ensure three key elements: optimal nutrition, increasing physical activity, and changing behavior. I’m saying someone is a candidate for medication if these three items have been tried or are currently being tried, but we are not seeing the weight drop. “

But even if the appetite signals get out of hand, medication alone cannot solve the problem. Diet, physical activity, and behavior changes still need to be part of the program.

Dr. Smolarz:

“The drugs make it possible to make these fundamentals even more successful. The drugs allow you to tolerate a reduced caloric intake. So it is one thing to say, you have to eat salad twice a day. You can be very hungry with 1200 or 1500 calories. The drugs, which act as appetite suppressants, make this possible. “

Like all drugs, the drugs used to treat obesity have a risk of side effects. Patients and clinicians need to weigh the costs and benefits of the various medication options and choose the most appropriate for their situation. And this may be another reason GPs don’t prescribe obesity medication.

Here again Dr. Smolarz:

“All drugs work a little differently, so it’s a challenge to master everything. Then the last piece [the] fundamental misunderstanding of obesity as a pure weakness of will that people simply have to eat better and that they should get their obesity under control. That’s just not clinical reality. “

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