Why losing weight is a battle with biology and your environment

17 March 2020

Why losing weight is a battle with biology and your environment

Hello All,

This puts a lot of explanation to the things we know about losing weight and being able to keep it off.  It is a fight against our own biology including our powerful brains!  Doomed for failure without help is what the research says (95% of people who lose significant weight on diets, end up regaining their weight - and more).  Thankfully weight loss surgery is often the key to helping people to make those long term habit and lifestyle changes that are essential for success.  The Holy Grail of weight loss surgery is maintaining the weight loss long term.  Obviously what I do with the operation is purely physical which doesn't necessarily address the brain/head side of the process - which can be equally powerful.  I often advise my patients that counselling sessions - 3 monthly for the first 2 years following surgery - are a priority in helping to optimise the thought processes/habit changes/cravings/emotional eating side of the journey.  Not everyone needs it, but it should certainly be considered as an adjunct to Bariatric Surgery.

Anyway, food for thought...

Keep smiling!


Weight loss should not be the primary motivation behind healthy lifestyle changes, according to researchers from the University of Alberta, Canada, who claim that there is a growing body of research showing that upwards of 95 percent of those who achieve any sort of meaningful weight loss will pack it back on, and then some, within a couple of years.

Dr Arya Sharma, who is chair in obesity research and management at the University of Alberta and medical director of the Alberta Health Services Provincial Obesity Strategy, explained that as we gain weight, our body's biology changes and will actually start defending that higher body weight as the new normal, regardless of how you put it on.

"As you start eating less, your body senses there's not enough calories coming in, and you start having cravings," he said. "In fact, you might even find food that you normally don't like - high-caloric food - will actually seem much more attractive to you."

Sharma said the brain has a whole bag of tricks at its disposal, with the sole purpose of trying to get you to eat - beginning with increasing appetite and heightening taste and smell. The next strategy your body employs to combat any substantial weight loss is to reduce the amount of calories it burns.

"If there's not enough calories coming in, the body turns down the thermostat," he said. "That's why people who lose weight often complain of feeling cold."

In addition, as we reduce the number of calories the body gets more fuel-efficient and is able to cut calorie consumption during physical activity.

"That's the big difference between biology and physics. If you look at your car, you can't teach your car to run on less fuel, but you can train your body to run on less fuel and you can become more fuel-efficient - it's an adaptive system."

When those three things are taken together - increasing appetite and burning fewer calories at rest and at play - along with genetics and the fact that most of us have a finite amount of willpower, Sharma said it doesn't matter what exercise program you follow or which diet you implement - your body's going to want those calories back.

"I liken it to pulling on a rubber band. You lose the weight and now you're pulling on this rubber band, and you have to keep pulling. The minute you let go, it's just going to snap back. That's what makes long-term weight loss so difficult."

Sharma said because weight loss and weight maintenance carry on basically forever, obesity needs to be treated as a chronic disease.

"When you have diabetes, and you need to follow a diet and take your insulin, you need to follow your diet and take insulin forever. It's the same thing."

He added the treatments that work best in the long term are the ones that fight this biology, such as bariatric surgery and medications that can block the adaptive responses of the body.

"The body can still fight it, which is why there are some people who have bariatric surgery or who take the medication and then go off, who still end up putting the weight back on," said Sharma. "That just tells you how powerful those mechanisms can be."

According to Kim Raine, an obesity researcher in the School of Public Health, we are unwittingly helping our nature to gain weight with a seismic shift in the last 40 or so years in our environment.

"We may be eating more than we used to and we may be less physically active than before, but it's not generally our choice to do that - it's that our environment has changed significantly," she said.

For instance, the ability to have food at our beck and call has increased exponentially in the last number of years. About a decade ago, Raine's lab assessed the relative amount of fast food and convenience stores compared with grocery stores in the city of Edmonton. They used fast food and convenience stores as a proxy for unhealthy high-calorie food and grocery stores as a proxy for where you at least have the option of getting something healthier.  They counted 61 grocery stores and 761 fast food and convenience stores.

"We've got this exposure to food like we've never had before - that's the physical environment."

Perhaps even more invasive than the availability of food is the constant bombardment of messages promoting unhealthy food. Raine noted that marketers of unhealthy foods and beverages spend more money in three days than governments trying to promote healthy eating spend in a year.

"And then we expect the nutrition education campaign that says 'eat your vegetables' to counteract that. It doesn't make a lot of sense."

The increase motorised transportation means we do not walk anywhere anymore and even well-meaning policies aimed at giving people greater access and increased choice to schools might be having a deleterious effect on physical activity.

Raine suggested open boundary policies that allow students to attend the school of their choice no matter where they live might be helping to drive the obesity epidemic too, as many kids are no longer walking to their neighbourhood school.

"Because even if we work out an hour a day, it doesn't necessarily make up for what you would have walking back and forth to school or work four times," she said.

"It's not a single one of those pieces that causes the problem, it's when you add them all up."

While schools themselves do their best to teach kids about nutrition, Raine said students can walk out into the hallway to find a vending machine filled with high-calorie junk food.

"We're fighting against an environment that is really pushing us to consume more and to be less active," she said. "We need to move beyond trying to teach people to cope with the environment and change the environment."

Raine said it can start in school. The University of Alberta-led APPLE Schools programme promotes the value of healthy eating and physical activity, but these programmes need to be mandatory and need to be better funded.

Restrictions on the marketing of unhealthy food and beverages to children would also help, Raine said. Such restrictions have been in place in Quebec since 1980, and research shows those children consume significantly less fast food and have lower obesity rates.

She said subsidising healthier foods and taxing high-sodium, high-sugar foods would also help, but added no one thing is going to solve the problem.

"We can learn from successes in tobacco control. Raising taxes, restricting access to minors or eliminating advertising - each one of those things individually did not make major changes to tobacco use, but collectively they changed the culture and denormalised tobacco use."

As for what we can do, health law and policy researcher Timothy Caulfield recommends steering clear of fad diets.

"These diets gain traction because people do lose weight. But they're losing weight because they pay attention to what they're eating for a little while," he said. "One thing I often say to people is, 'Can you name a single diet that worked long-term?' If that existed, we would know."

He said what frustrates him most is that almost all of the marketing and pop-culture references to diet and exercise are tied to weight loss and aesthetics.

"The best diet is the diet that works for you, is sustainable, is healthy and is enjoyable. If it's not enjoyable, it's not going to be sustainable."

University of Alberta nutrition expert, Sabina Valentine, said one of the problems with fad diets is they often target foods we need, like protein, fat and carbohydrates.

"I don't want people going out and eating loads and loads of fat, which happens in the keto diet. In moderate amounts - perhaps 30 percent of your diet - fat contributes to a healthy diet."

Same with carbohydrates, which Valentine said have got a bad rap in the last decade, largely because of sugar.

"Here are all these people avoiding carbohydrates, but they contain fibre, which plays an important role not only for decreasing health risks - like cancer and heart disease - but also for making you feel full."

Rather than restrictive fad diets, Valentine said healthy eating should focus on making common-sense decisions and not being too hard on yourself after enjoying dessert at a party, for instance.

"Learning how to include some of those yummy things in your diet kind of gives you that stick-to-itiveness," she said.  

Mental health service use after bariatric surgery

14 January 2020

Mental health service use after bariatric surgery

Happy New Year Everyone!

The summary of this study is sufficiently vague to make the conclusion difficult to accept at face value.  I think 'mental health service use' could cover a whole lot of different interactions that post-bariatric surgery patients may undertake with mental health services that don't equate to a decline in mental health status.  I agree that whilst Bariatric surgery is a purely physical intervention ie performing a Gastric Sleeve or Bypass, there are also a whole raft of emotional and psychological effects that aren't fully anticipated by those undergoing the operation.  Most of my patients don't see a psychologist or counsellor for eating issues prior to surgery and it is not until about 3 months down the track following surgery that patients fully understand the non-physical effects of the operation.  At this stage it is highly advisable to see someone with skills in helping patients to process some of these non-physical side effects.  For most of my patients the psychological benefits of surgery and significant weight loss are deemed a positive benefit rather than a negative outcome. 

I hope this makes sense to you.

Look forward to meeting you soon!

Kind regards,

Steph Ulmer

JAMAMorgan DJR, et al. | January 08, 2020


Using data from Western Australian Department of Health Data Linkage Branch records, researchers conducted this statewide, mirror-image, longitudinal cohort study to explore the relationship of bariatric surgery with the incidence of outpatient, emergency department, and inpatient mental health service use. Data of a total of 24,766 patients [mean age: 42.5 (11.7) years; 19,144 (77.3%): women] who underwent index bariatric surgery were obtained. One in six patients undergoing bariatric surgery used at least one perioperative episode of a mental health service over a 10-year study period. Significantly more common outpatient, emergency department, and inpatient psychiatric presentations were observed after surgery compared with before surgery. This was especially noted among those who had prior psychiatric illnesses or had surgical complications that needed further surgery. It is recommended that patients be regularly assessed and advised about the possible associations of bariatric surgery with mental health outcomes.

Bariatric surgery may prevent strokes and extend life expectancy

19 November 2019

Bariatric surgery may prevent strokes and extend life expectancy

This is hot-off-the-press research and as robust as you can get it! I say that because of the type of study it is and the length of time the patients have been followed up ie 11 years.  It is what we call a Case-Control study - so every patient included in the study who has had Bariatric surgery is matched (for age, sex, BMI, smoking status etc) with somebody who hasn't had Bariatric surgery.  This means, in essence, that their outcomes can be compared directly because the only thing that is different between the matched patients is whether they have had surgery or not.    And what a stunning result - 69% less likely to have a Stroke and 68% less likely to die in the study period.  Wow!  There is no other treatment that can give as significant a health benefit as Weight loss surgery that I know of! Well and truly dispelling the long held myth that Weight loss surgery is an aesthetic procedure.  Seems laughable now in light of these kinds of results.

Hope this helps you in your decision making process!




Patients with obesity who undergo bariatric surgery live longer and are less likely to experience a clot-caused stroke than those who do not, according to preliminary research to be presented at the American Heart Association's Scientific Sessions 2019, in Philadelphia.

"Obesity is associated with a number of risk factors for heart disease and we know that bariatric surgery - which alters the digestive system to induce weight loss - can help reduce these risk factors and improve their control. In this study, we examined if bariatric surgery helps reduce stroke risk," said Dr Maddalena Ardissino, co-lead author of the study and academic foundation doctor at the Imperial College London in the United Kingdom.

In the largest and longest study of bariatric surgery to-date, researchers analysed the health care records of more than 4,200 patients in the UK who had bariatric surgery and compared them to an equal number of people who did not have bariatric surgery, matched by age, gender and weight-for-height. At the time of the surgery, none of the participants had previously had a stroke. The records were part of the Clinical Practice Research Datalink, a large ongoing initiative that contains anonymous coded primary and some secondary health care data on more than 7% of all patients in the country.

During an average follow-up of 11 years and after adjusting for all major risk factors and medication use, researchers found:

  • 73 of the participants had a brain bleed, clot-caused stroke or mini-stroke;
  • 229 patients died from any cause;
  • Those who received bariatric surgery were 69% less likely to experience a clot-caused stroke;
  • Rates of brain bleeds were not reduced by weight loss surgery; and
  • Those who underwent bariatric surgery were 68% less likely to die during the follow-up period than those who did not have surgery.

"These findings call for increased awareness and implementation of bariatric surgery as a treatment step for obese patients who are unable to achieve adequate weight loss through lifestyle and medication therapy," said Ardissino. "Currently, only a small fraction of people with obesity receive bariatric surgery."

A shift in the perception of bariatric surgery is needed. Bariatric surgery used to be seen as an aesthetic procedure undergone by only a minority of the eligible population. Considering the quickly emerging evidence on its long-term benefits, the surgery must be viewed as a potentially death-preventing and standard-of-care procedure that should be discussed with all eligible patients, Ardissino add.

This study can only show an association and cannot prove cause-and-effect. Although the data was from the UK, researchers say the results should apply to other western countries with similar populations.


Thank you for your enquiry. We will be in touch.

Ask Dr Ulmer a Question

We are here to help, contact us today to receive a personal response from Stephanie