This article was first published in The Montreal Gazette.
Medications like semaglutide (Ozempic, Wegovy) have changed how we talk about weight loss. Obesity was, and often still is, seen as a lifestyle problem rather than a chronic disease needing a chronic treatment. But in the frenzy surrounding the new-found popularity of this drug class, we still have a major unanswered question: What role do lifestyle interventions play in this new post-medication era?
If losing weight was easy, everyone would do it. Telling people to diet and exercise is well-meaning advice. But it’s not useful. Patients already want to change their habits. But desire doesn’t get you to the top of Everest. Desire gets you to base camp. Mountaineering skills get you to the top of Everest.
Finding behavioural interventions that work poses several problems. Most fad diets work at first, but clinically meaningful interventions have to have sustained benefits. It’s not enough to lose the weight; you also have to keep it off. Also, any program or intervention has to be applicable and scalable to the population as a whole. It would be easy to eat healthy if you had a private chef, but private chefs are not a practical way to deal with the rising rates of obesity.
Two recent studies published in the Journal of the American Medical Association tested two different behavioural interventions to help with weight loss. In the first study, researchers used a wireless feedback system made up of a Wi-Fi activity tracker and an electronic scale that fed information back into a smartphone app that provided daily feedback on weight loss goals. Half of the study participants also received phone-based coaching on a weekly basis. Anyone not achieving a half pound of weight loss per week received additional behavioural interventions in the form of text message reminders and/or meal replacements. At six months, the group who received the wireless feedback system lost 2.8 kilograms (around six pounds). Those who had the extra coaching lost an additional two kilograms (around four and a half pounds).
The second study tested a program where participants got daily text messages to help them maintain their weight loss goals. A control group received no messages, one group got just text messages, and a third group got daily text messages plus financial incentives (nearly CAN$700) if they met all their weight-loss goals at one year. The control group lost 1.3 per cent of their body weight over the trial, the text-message group lost 2.7 per cent and the group with the added financial incentives lost 3.2 per cent.
These two studies taken together raise a difficult question. What role do behavioural interventions like these have in this post-Ozempic era? The interventions did work, but their benefits were modest. While most people think diet and exercise are free, designing programs like these to help a wide swath of the population are difficult and resource-intensive to scale up.
Medically speaking you generally want to see at least five per cent weight loss for any weight-loss intervention, and maintaining at least 10 per cent over the long term is probably necessary to have meaningful clinical benefits. Remember the point of all this is not esthetics but disease prevention.
These studies were interesting because they tested creative and fairly innovative approaches to weight loss. But the benefits were small and most did not achieve even five per cent weight loss, though some lost quite a bit of weight. Balancing high-cost medical therapy against cheaper but more modest behavioural interventions is never easy. Programs like this may be appropriate for some people who really respond to extra external motivation or those who need modest weight loss to counteract a recent life event (like illness or injury) that led to weight gain. But just as medication is not appropriate to everyone, behavioural interventions won’t work in everyone either.
In the end, these are creative solutions that won’t be applicable to everyone. That’s why weight loss is so hard.
