Non surgical weight loss

Not losing weight is not your fault

As people struggling to lose weight well understand, in most cases ‘eating a better diet’ or ‘doing more exercise’ does not work (although these are good for you in other ways).  This is because once you are past a certain age, and past a certain weight, the weight has become ‘locked in’, probably due to the gut bacteria we call the ‘intestinal microbiome’.  It has been well-known for many years that in lab mice, one can transfer obesity from one mouse to another by transferring the intestinal microbiome in the stool.  The exact mechanism by which the intestinal microbiome influences our weight is not known, but, for instance, increasing appetite if we lose weight is probably one factor. As such, obesity is not a problem of self-control or a personal weakness, but is a long term disease, and requires a long term solution.

Surgery

For decades the only reliable way of losing weight in those with obesity, assuming that there is not a simple problem such as excessive consumption of soft drinks or alcohol, has been surgery.  Commonly-employed surgeries include Roux-en-Y gastric bypass (RYGB) which alters the ‘plumbing’ of the gut, and laparoscopic sleeve gastrectomy (LSG) where about 80% of the stomach is removed.  These are both effective at causing weight loss that is usually sustained, assuming dietary changes are followed.  The major problem with these surgeries, however, is that if something goes wrong after the surgery, they cannot be reversed.  They are by their nature mutilating. In terms of common problems with surgeries, LSG appears to cause bad reflux symptoms in a third a those who have that operation, and can cause swallowing to deteriorate over time. For the RYGB operation, issues with ulcers and gallstone disease are common, and vitamin supplements are required for life.  There is also a significant recovery period after surgery, usually at least a month.

Medications

Many people will now be aware of the new diabetes medications that are being used successfully for weight loss, notably in the USA.  These drugs are called ‘GLP-1 receptor agonists’, and the most well-known currently is semaglutide which is sold under the trade names Ozempic (for diabetes) and Wegovy (for weight loss).  A newer more powerful version is tirzepatide, which is a GLP-1 and GIP receptor agonist, marketed as Mounjaro. In NZ there are also weaker versions used to treat diabetes or self-funded for weight loss: dulaglutide (Trulicity) and liraglutide (Saxenda). Although there are several reasons why these drugs can cause weight loss, probably the main reason is they suppress appetite.  They also have effects on hedonism (pleasure seeking): for this reason they may become a useful treatment for alcohol misuse and other forms of compulsive behaviour, and they appear to change the palate of many people, reducing for instance the desire for sweet foods. There is evidence that semaglutide is be useful in reducing binge eating episodes in those with Binge Eating Disorder and Bulimia Nervosa.

The major downside of these medications, however, is that they are only effective when you are taking them and weight regain will occur when they are stopped. They often cause low grade symptoms such as nausea, diarrhoea or constipation that people get tired of over time.  They may reduce enjoyment of eating in social situations, and the weight loss is often disproportionately noticed in the face (‘Ozempic face’). There are potential complications such as pancreatitis, gallbladder disease, and, rarely, vision loss. They cannot be used in those planning pregnancy nor in those breast feeding. In addition, they are very expensive as an American cost-effectiveness study published in 2024 showed: at current pricing and after 5 years of use (remembering that you have to take it long term) semaglutide is three times more expensive than the endoscopic treatment described below. Those taking these drugs will lose weight for 6-12 months, then weight loss will bottom out, yet the medication will still need to be taken and paid for in the long term - after a while most people just give up and weight regain occurs. As such, on their own these medications may not be sufficient.

Non surgical endoscopic techniques

The third effective weight loss method is now being offered at Wakefield Hospital.  Endoscopic sleeve gastroplasty (ESG) was developed first in 2013 as a way of ‘copying’ the surgery LSG by using a stitching device on an endoscope to reduce the size of the stomach.  With a reduced stomach size you cannot eat large meals, and you also feel fuller for longer after a small meal.  None of the stomach is actually removed, so if things go wrong the procedure is actually reversible, and, unlike LSG, reflux will likely get better after an ESG.  By performing the entire procedure through the mouth and not cutting the skin, recovery is much faster, and complications are much fewer.  Most patients go home the same day, and can go back to work within a few days. There are no restrictions on driving or lifting after the procedure. ESG is now the most commonly performed obesity procedure in the world, with 5 year results comparable with LSG in those with a BMI of 30 to 40.  Aside from its efficacy and rapid recovery, ESG is a one-off cost unlike the medications described above.

Another option available in New Zealand is an intragastric balloon. This option involves inserting a deflated balloon into the stomach via endoscopy, inflating it to fill up much of the stomach, and leaving it in place for up to a year. After that time it is deflated and removed. This can cause a significant amount of weight loss, but it is a temporary measure and weight loss is rarely sustained without additional measures such as GLP-1 receptor agonists. In addition it is often poorly tolerated, and most studies show that a majority of patients never want it repeated as the experience was so unpleasant.

At present neither ESG or LSG surgery would be considered first choice as the treatment for longstanding type 2 diabetes. This disease develops because a long term diet containing the wrong nutrients (high sugar, high fat, low fibre) leads to dysfunction in the duodenum and liver. Of note, the duodenal lining changes so that there are more pumps to absorb sugars and fewer cells that regulate appetite. At present the only treatment that reliably reverses type 2 diabetes is RYGB which causes food to bypass the duodenum. GLP-1 receptor agonists might be a good choice as they are first and foremost diabetes medications that have protective effects on many organs that are damaged by diabetes. There are, however, advanced trials underway in Europe and the US with endoscopic devices that can treat the abnormal duodenum, regenerate normal cells, and in a percentage of cases reverse type 2 diabetes. If these become available then ESG plus duodenal treatment may become an excellent choice for those with type 2 diabetes.

It’s more than just the procedure

It is important to understand, however, that no measure on its own is able to cure obesity. All of the techniques and medications described above require changing the lifestyle and dietary problems that led to the weight gain in the first place, and those changes need to be lifelong. All current treatments for obesity give the opportunity to effectively lose weight for 6-12 months, and potentially make keeping the weight off easier, but also require a commitment to change. For that reason, dietetic follow-up is part of the weight loss package that we offer, and we recommend the services of a health psychologist as well. For those looking for evidence-based information about the optimum diet to maintain weight and health, we recommend reading material from Dr Tim Spector, a microbiome researcher and writer from London.

Dr Rees Cameron is happy to meet with you to discuss the pros and cons of the different weight loss options, and whether ESG is a good choice for you.  If you wish to explore ESG as an option, then he recommends that you also arrange an appointment with the dietitians of FoodSavvy who can provide a dietary assessment to better inform the best way forward.