Treating obesity using drugs and surgery

What is harmful obesity?

Most doctors use body mass index (BMI) (in Norwegian) to determine if you are a healthy weight relative to your height. BMI is a number that is calculated based on your height in metres and your weight in kilograms. There are BMI calculators available online. A BMI of 30 or higher is defined as obese and can lead to increased health risks. A BMI of 40 or higher is defined as morbidly obese. 

Harmful obesity means more than just being a few kilograms too heavy. Obesity causes an increased risk of type 2 diabetes, high blood pressure (in Norwegian), heart disease, cancer and osteoarthritis (in Norwegian). Many people also experience reduced quality of life. When doctors talk about a ‘healthy’ weight, they refer to a weight that reduces the risk of developing serious health issues. 

You may believe that you are not eating a lot, but obesity is caused by consuming more calories than your body burns. Unfortunately, you only need to eat a little bit more than usual to gain weight. 

Treatment of obesity

In order to lose weight, you need to consume fewer calories than you burn.You have the best chance of losing weight if you combine fewer calories and more exercise with behavioural therapy. Following weight loss, you need to maintain your new habits in order to not gain weight again (yo-yo dieting). 

If you have been unable to lose weight through lifestyle changes alone, drugs or surgery may be recommended as a last resort. 

Medications 

There are four authorised drugs that can help you lose weight in Norway. These are called 

• semaglutide 
• liraglutide 
• orlistat 
• naltrexone/bupropion 

Most people can get help from their GP, but there are also specialist obesity outpatient clinics. 

If you have a BMI of more than 30, or 27 together with at least one weight-related comorbidity, such as pre-diabetes/diabetes, high blood pressure, cardiovascular disease, severely elevated amounts of lipids in the blood (dyslipidaemia) or sleep apnoea that causes you to stop breathing, these could be relevant treatments if you have been unsuccessful in managing your weight through lifestyle measures. 

Most people who stop taking weight loss drugs regain the weight they lose. It is therefore likely that many people will continue with drug therapy for a prolonged period of time. The treatment is relatively expensive but at the same time food costs are reduced.

Semaglutide and liraglutide 

Semaglutide and liraglutide are injections that have been used for the treatment of type 2 diabetes in Norway and were later authorised for weight management. The drugs are effective for many people and have become very popular. This will likely lead to a decreased need for surgical treatment. 

The drugs are most effective for those who feel hungry soon after a meal (hungry gut). After losing 10-15 per cent of their starting weight in a year, many people report improved well-being and finding it easier to exercise. Physical activity is important for health even if you are not losing any further weight. The drugs result in hunger suppression and quicker satiety, making it easier to eat less. 

The most common side effects are 

• diarrhoea 
• constipation 
• nausea 
• vomiting 

These occur more frequently at the start of treatment and will usually decrease over the course of a few days or weeks of continued treatment. Alternatively, a smaller dose can be administered. 

Orlistat and naltrexone/bupropion are prescribed less often following the introduction of semaglutide and liraglutide. 

Orlistat

Orlistat reduces the absorption of fat in the intestines by around a third. If you combine orlistat with a low-calorie diet and regular exercise, you could achieve a weight loss of around five per cent in a year. 

Orlistat may cause side effects such as 

• steatorrhoea 
• gas (bloating) 
• nausea 
• vomiting 

These side effects will decrease if you eat a low-fat diet (less than 30 per cent fat). 

You can get advice from a nutritionist. Some people will be at risk of vitamin A, D, E and K deficiency, but this can be managed using vitamin supplements. 

Naltrexone/bupropion 

Naltrexone/bupropion are drugs used for the treatment of alcohol and nicotine addiction. The drugs also reduce appetite and you can expect a weight loss of between five and eight per cent during treatment. 

The most common side effects of naltrexone/bupropion are 

• nausea 
• constipation 
• vomiting 
• dizziness 
• dry mouth 

After discontinuing tablet treatment, many people will return to their starting weight. The treatment is expensive, and it is important to think carefully before choosing this option. 

There are other diet pills, but these are not authorised for use in Norway and are not recommended. Some of them can be dangerous. If you are considering taking diet pills or herbal remedies, you should discuss it with your doctor first.

Surgery 

If you are very overweight and meet certain criteria, surgical treatment could help you eat less and lose weight. The surgery is extensive and is performed only in the event of morbid obesity and when other treatment has not been successful. 

The most relevant surgical procedures are: 

• Gastric bypass: The surgeon reduces the size of the stomach by closing off a large part of the stomach and part of the small intestine. The remainder of the small intestine is connected to the reduced stomach. 
• Gastric banding: An adjustable band is fitted around the stomach to make it smaller. 
• Biliopancreatic diversion: The lowermost part of the stomach is removed to make it smaller. The small intestine is shortened. 
• Sleeve gastrectomy: The procedure closes off three quarters of the stomach, leaving a narrow tube. 

You can lose a lot of weight after surgery. Some people get to a normal weight and blood pressure and blood sugar may improve or normalise in people with high blood pressure or type 2 diabetes. 

It is necessary to follow a strict diet after the procedure. The treatment means that you will feel full after small portions, as the stomach is unable to hold as much food as before. 

Unfortunately, the surgery may be accompanied by side effects such as 

• nausea 
• diarrhoea 
• constipation (obstipation) 
• acid reflux 

A nutritionist will advise you on which vitamin supplements you should take. In connection with the surgery itself, there is a risk of bleeding, wound infections or pneumonia. This risk is reduced by having surgery with an experienced surgeon at a hospital where many such procedures are carried out. 

There is a small chance of dying during surgery or shortly thereafter. In studies, 3 in 1000 people died during or within the first month of surgery. 

Some people are asked to lose weight or stop smoking before weight loss surgery. This reduces the risk of complications. 

Surgery does not work for everyone. Some people do not lose weight or experience only a temporary effect. 

Benefits of weight loss

There are many benefits to losing weight (in Norwegian) when morbidly obese. The stress on weight-bearing joints and on the heart is reduced, as is the risk of type 2 diabetes and cancer. However, many people find it difficult to lose weight through lifestyle changes. Drugs and surgery can be the last resort for those who struggle the most.