Non‐Surgical Management of Obesity

Non‐Surgical Management of Obesity

Petra Hanson and Thomas M. Barber


The global obesity epidemic is one of the biggest threats to our health, accounting for much chronic ill health globally including at least 50 obesity‐related co‐morbidities. Much obesity‐related ill‐health stems from cardio‐metabolic dysfunction, including type 2 diabetes mellitus (T2D), hypertension and other features of the metabolic syndrome, and obesity‐related malignancies, such as endometrial carcinoma. Socio‐economic costs of obesity are substantial, a large proportion of which stem from the application of management strategies for both obesity per se and the many obesity‐related co‐morbidities.

NICE endorses a tiered and stepwise approach to obesity management. Such an approach commences with public health messages, and progress through community and then hospital‐based approaches and finally bariatric surgery. This pyramidal structure reflects the availability of each tier to the populace, with relatively few bariatric procedures (approximately 6000 per year in the UK). It is interesting to observe that our provision for weight‐loss services and the balance of evidence for effectiveness seems to follow a reciprocal relationship: our best evidence for longer term weight‐loss efficacy relates to bariatric surgery, the least available and most restricted obesity‐related resource.

In this chapter, we consider the non‐surgical management strategies for obesity. Following an initial discussion of obesity management from a patient perspective, including the goals of obesity management, we discuss the main lifestyle strategies for weight loss, including sleep, mindfulness, non‐sedentariness and diet. We then summarise the main pharmacological therapies available for obesity management and consider the challenges of weight maintenance and the practical learning points from such insight. Finally, we propose some future directions for innovative development of obesity management strategies.

Obesity Management from a Patient Perspective

One of the challenges of effective obesity management is the choice of the most appropriate strategy. There are many strategies available. The latest NICE guidelines on obesity management addresses this challenge to some degree, through the tiered and stepwise approach of public health messages, community‐based lifestyle programmes, hospital‐based non‐surgical management and finally bariatric surgery. However, even with this NICE‐endorsed broad structure, there are many permutations and choices required.

Choice of management strategy should normally involve the patient and may include close family members or friends. In many cases, there may be preclusions to engagement in physical activity. These include, for example, poor self‐esteem or agoraphobia, social embarrassment or shame (particularly regarding physical activity in public), osteoarthritis causing pain in weight‐bearing joints, lack of motivation and enthusiasm for engagement in physical activity, lack of time, lack of knowledge regarding physical activities or a combination of all of these factors. It is important for healthcare professionals to explore these factors sensitively, as this insight will likely inform choice of management strategy. Furthermore, a patient will often have already tried various diets in the past, and such experiences are likely to influence their enthusiasm for engagement in further dietary programmes. Choice of medical therapies is also likely to be influenced by prior experiences of therapies (such as Orlistat and any associated side effects), and affordability and availability of medical therapies in each locality.

Effective management of obesity merits a multi‐disciplinary team (MDT) approach. MDT members depend on the tier and location of each service. However, given the central role of diet in the development and maintenance of obesity, it seems logical that dietary support should be a requisite regardless of tier or location. In a perfect world and given unlimited resource, it would be desirable for focused psychological support to form an important role of MDT teams regardless of tier or setting. However, many teams lack a psychological element, even at the tier 3 level. Given the many psychological factors that contribute towards and associate with weight gain, and the stigmatisation of obesity in our society, effective management of obesity is impoverished and limited without some form of psychological support. Simply providing healthy eating and lifestyle advice is inadequate for many patients whose problem does not lie with inadequate knowledge, but with inadequate psychological tools and strategies for translating healthy lifestyle advice into practice.

Another important consideration for effective obesity management is its location. Although the definition of the NICE‐endorsed tier system for obesity management includes location, there is no logical reason why any aspect of obesity management other than bariatric surgery needs to occur within a hospital setting. Indeed, some tier 3 services for obesity management are community‐based. From a patient’s perspective, it may be more desirable to attend a community rather than hospital‐based service. There are many reasons for this, including those relating to convenience. However, on a broader level, support based within a hospital setting automatically places a medicalised perspective on the patient’s encounter with the obesity team. In certain scenarios, this could have the potential to distract, particularly in those patients who have no medical sequelae of obesity and simply want to lose weight.

Finally, it is important to address the issue of treatment goals. On one level, it may seem obvious that in a patient attending an obesity service, effective weight loss should be the main goal to achieve. Indeed, in many cases this is true. However, to focus purely on weight loss to the detriment of everything else would be a mistake. One common scenario encountered in clinical practice relates to adjustment reactions, and the effects on mood and well‐being. It would be naive to assume that successful weight loss always associates with improved mood. In reality, weight loss can and often does actually worsen mood. A common psychological trap is that ‘If I could only lose this amount of weight, then I will feel much better about myself and have achieved happiness’. When there is weight loss without the expected positive changes in mood and well‐being, this in itself can be a disappointment, which then instils despair and worsens mood. Whatever goals are set therefore for each individual patient, it is always important to carefully consider the effects of achieving such goals on mood and well‐being, and to have appropriate support in place to address these factors. Arguably, improvement in well‐being (both mental and physical) should be a goal in itself, even in the absence of meaningful weight loss. This is a useful mantra for all healthcare professionals involved in obesity management.

Lifestyle Management of Obesity

Lifestyle forms a mainstay of obesity management (summarised in Figure 5.1). Indeed, healthy lifestyle measures transcend obesity management, and should apply to all of us, regardless of our BMI or degree of adiposity. The public perception of healthy living normally focuses on a familiar couple: diet and exercise. This is not surprising given the emphasis of public health messages for decades on diet and exercise, instilled in most of us from a very young age. Diet and exercise are, of course, important elements of healthy living. However, to optimise their successful application, it is essential to ensure physiological and mental readiness for such changes. There is evidence, for example, that the success of applying a calorie‐restricted diet with regard to weight loss depends on sleep sufficiency. In our view, physiological and mental preparedness should take precedent over all other aspects of healthy lifestyle and justify focused attention as important public health messages in their own right. This includes the importance of sleep sufficiency, not only as a strategy for successful weight loss but also as a strategy to optimise future health holistically given the fundamental importance of sleep for virtually every aspect of physiology, including metabolic health. Furthermore, whilst emphasis on exercise is important, the term ‘exercise’ can conjure an image of gym‐based physical work out, with associated demotivating effects sometimes when managing obese patients. In our view, emphasis on physical activity is important, and in particular avoidance of sedentary behaviour. Therefore, in the outline of lifestyle management below, we have replaced the familiar couple of ‘diet and exercise’ with a quintessential quartet of sleep sufficiency, mindfulness, non‐sedentariness and balanced diet.

Schematic illustration of the four pillars of lifestyle management.

Figure 5.1 The four pillars of lifestyle management.

Sleep Sufficiency

Sleep deprivation is a modern problem. During the twentieth century (between 1905 and 2008), there has been a rapid and consistent decline in sleep duration (average decrease of >1 hour per night), based on data from >690 000 children and adolescents from across 20 countries in a large systematic review on data. There are many reasons for the modern‐day phenomenon of sleep deprivation. These include our 24‐hour availability of provisions and entertainment, with emergence of our modern ‘instant access’ culture. Accordingly, for many of us there has been a transformation of our modern‐day lifestyles and daily routine. An unfortunate consequence being encroachment on our natural time for sleep. To compound this scenario, natural lighting and blue light from screens hinder melatonin production, with implications for sleepiness. Furthermore, more of us now live in cities than at any other time of human history, with associated noise pollution also hampering restful sleep. A perfect storm for sleep deprivation has occurred in recent decades, compounded by an apparent societal nonchalance.

Societal insouciance for sleep deprivation is unfortunate given that sleep deprivation, even for just one hour per night, has far‐reaching negative effects. For example, many children diagnosed with attention deficit hyperactivity disorder (ADHD) actually have underlying sleep deprivation. Sleep literally influences every aspect of physiology. Appetite regulation is no exception. In one study, appetite enhancement (driven by changes in appetite hormones including ghrelin and leptin) occurred after just two nights of sleep deprivation, and this resulted in enhanced caloric ingestion and a preference for sweet and fatty foods. Sleep deprivation associates with increased BMI. In one study in children, a U‐shaped relationship occurred between sleep duration and obesity risk amongst girls: the lowest risk of obesity occurred in girls who slept for eight hours per night. Perhaps resulting from effects on appetite hormone regulation and implications for success at diet modification, sleep deprivation hampers one’s ability to lose weight. In short, sleep sufficiency is a prerequisite for effective weight loss through lifestyle change. Sleep sufficiency is a lifestyle pillar on which diet and physical activity rest. The importance of sleep sufficiency in the management of obesity cannot be overstated and should usually be the first lifestyle goal to achieve. Unfortunately, there has been neglect traditionally of the importance of sleep sufficiency as an effective weight‐loss strategy. This apparent widespread lack of appreciation of the importance of sleep manifests frequently when patients express surprise when discussing sleep quality and sufficiency as part of an effective strategy for obesity management. This reflects a long‐standing lack of effective public health messages regarding the importance of sleep generally.

Optimisation of sleep sufficiency within the populace is important. Public health messages regarding the importance of sleep would be desirable. Before engaging on any weight‐loss programme, regardless of its nature, it is imperative, in our view, to optimise sleep quality and duration as a prerequisite. This will improve the likelihood of success. There needs to be radical change in the way society and culture view sleep and its importance. This should include educational programmes, particularly for our children. We need to optimise our sleeping environments, to include limitation of noise and light and often a cooler environment. Our daily routine should avoid food, exercise, and blue and bright light in the hour before sleep. Finally, given the importance of sleep for work efficiency and well‐being, employers should encourage and promote sleep sufficiency in their employees.


Mindfulness refers to a heightened state of mind, increasingly used in healthcare to optimise treatment outcomes. Our own group showed evidence to support adoption of mindfulness techniques (taught in the context of group sessions), in obese patients attending our tier 3 service. We demonstrated improved healthy eating‐related behaviours that translated into superior weight loss (compared with patients who did not receive mindfulness training). Furthermore, a reduction of binge and impulsive eating‐related behaviours and increased physical activity transpired in a meta‐analysis of adoption of mindfulness techniques in overweight and obese adults.

Our modern‐day environment is full of distractions, and not very conducive often to adopting a more mindful approach to lifestyle. This is particularly apt regarding lifestyle management of obesity. For many of us leading busy and stressful lives, there seems to be little time set aside for quiet contemplation and reflection: engagement of both being a requirement for successful adoption of mindfulness. Furthermore, many aspects of our modern lifestyles seem to be habitualised and enshrined in cultural and social norms. The pattern of three meals per day, familiar to many of us, is an example of this. Also, another example is the use of food at social occasions, and the communal eating of food from a buffet at social gatherings, at which eating behaviour is driven perhaps more by social norms than by appetite for food per se. Such cultural and social norms with habitualisation of daily routines can foster an approach to eating that is the antithesis of mindful: that of ‘mindlessness’.

As with sleep sufficiency, successful adoption of lifestyle strategies for weight loss heavily depends on developing a mindset that is conducive and facilitative to such an approach. Mindfulness is an excellent example of this. One challenge for the future will be to translate our tier 3 group‐based teaching of mindfulness to a much wider population that could possibly benefit from such an approach. Options include self‐taught programmes, possibly via an online tool or immersive technologies such as virtual reality to simulate group‐based learning for example. Through scaling mindfulness teaching to the population level, we could make mindfulness accessible to all, thereby optimising the success of lifestyle approaches to weight loss.


Physical inactivity or sedentariness includes both sitting and lying. In recent years, there has been much interest in the adverse metabolic and health implications of sedentary behaviour. Sedentariness associates with adiposity and may contribute towards appetite dysregulation and caloric overconsumption. In patients with T2D, sedentary behaviour has an adverse effect on glycaemic control. Furthermore, the interruption of sedentary behaviour during the day with minimal activity bouts every 30 minutes has transformative effects on glycaemic control that persists throughout the entire 24‐hour period.

Avoidance of sedentary behaviour through physical activity includes any bodily movement that increases energy expenditure. Conversely, physical exercise is planned, structured and repetitive bodily movements to improve or maintain physical fitness. Ideally, lifestyle change for obesity should encourage increases in both physical activity and physical exercise. However, patients with obesity often find physical exercise challenging, for a variety of reasons. These include coexistence of osteoarthritis affecting weight‐bearing joints causing pain on exercise, thereby physically limiting exercise ability. Furthermore, exercise is more effortful in obesity simply because of additional weight to move. Breathing in obesity can also be more effortful due to increased thoracic adiposity, and obesity associates with heart failure (with preserved systolic function). The stigma of obesity within our society can also result in embarrassment experienced by patients, and this combined with low self‐esteem can be hugely demotivating and non‐conducive to engaging in a fitness programme in a public area. Although exercise should generally be encouraged, a more pragmatic approach would be to encourage improved physical activity initially, and then to progress to exercise perhaps once confidence has improved.

Moderate physical activity for >150 minutes per week is effective at limiting weight gain, and for at least 250 minutes per week can result in significant weight loss. Engagement in lifestyle activities, even without physical exercise, can improve cardio‐respiratory fitness and optimise weight loss. Given the difficulties of engagement in exercise experienced by many patients with obesity outlined above, and the clear benefits of engagement in physical activity and avoidance of sedentariness, we should tailor our advice accordingly. Without diminishing the importance of physical exercise, we should perhaps prioritise encouragement of movement, physical activity and avoidance of sedentary behaviour. In practice, this means avoidance of sitting or lying for long periods. By definition, just standing up is a non‐sedentary behaviour. Therefore, let us all stand up for non‐sedentariness.

Balanced Diet

It is beyond the scope of this chapter to explore in detail the dietary options for patients with obesity. Rather, we outline general dietary principles. There is much uncertainty and controversy regarding nutritional management of obesity, reflected by differences between guidelines from esteemed bodies, and the frequent revisions over the years, and compounded by a plethora of ‘fad’ diets that may promise rapid weight‐loss effects, but many of which may lack scientific credibility. It appears that no single dietary strategy is superior to any other regarding weight loss and maintenance within the obese population. It is not surprising that patients and indeed some healthcare professionals are confused and bewildered regarding dietary advice on obesity. Some of the controversy regarding dietary management of obesity relates to the role of macronutrient content versus energy deficit (based on caloric content) of foods and consumption of natural rather than processed foods. A combination of these approaches is likely to be most effective, and importantly also to maintain a healthy balanced diet, without nutritional restrictions or exaggerations.

To lose weight requires a negative energy balance. However, macronutrient restriction may be less effective for longer term weight loss as originally believed. Realistic weight‐loss goals are important, and 5–10% weight loss in the first six months (with improvement in cardio‐metabolic risk) is commonly used. Ideally, dietary management of obesity should consist of low energy density, with application that is both continuous and easy for the patient to comply with. Frequent self‐monitoring of weight is a predictor of long‐term success of weight loss. Other markers of success include low‐fat intake, reduced consumption of unhealthy snacks and consistent food intake.

Low‐Carbohydrate Diet

The rationale for low‐carbohydrate diet stemmed from the Atkins diet. Over the longer term, compliance with a low‐carbohydrate diet is challenging, and such diets may worsen cardiovascular risk from increased LDL cholesterol. Very low carbohydrate ketogenic diets appear to be effective at promoting weight loss in the short term. There is conflicting data regarding the short‐term effects of low‐carbohydrate diets on weight loss, and limited data on safety and efficacy to support their usage beyond one year.

Low‐Fat Diet

Low‐fat diets have formed a basis for weight‐loss recommendations for decades. These recommendations stem from relative satiating effects between fat and carbohydrate, rate of absorption of fat from the gut, thermogenic effects of fat and the potential negative impact of fat on the intestinal microbiota with implications for further weight‐loss attempts. Furthermore, fat contains more calories than carbohydrate (9 kcal g−1 versus 4 kcal g−1

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May 14, 2023 | Posted by in GENERAL SURGERY | Comments Off on Non‐Surgical Management of Obesity

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