Obesity as a Disease - Medication

The "cheating" isn't a helpful term anymore. What actually happens is someone starts reducing their calories - therefore "on a diet" - and they can stick to that for a period of time (different for everyone). Sometimes they lose 5-10% of their body weight over a few weeks. However, what the scientific studies now show is that their body increases their hunger hormones, decreases their fullness hormones and increases the dopamine they get from high calorie-dense foods. There's no "pushing through" that. It's like holding your breath - eventually you have to breathe. So they end up eating the same calories that they ate before starting the diet. Except this time the body has thrown an extra spanner in the works. Because it believes you have gone through a period of food scarcity, it reduces your metabolism slightly. That means that you go back to eating the same calories as you did before starting the diet, and not only do you go back up to your original weight, but you put another 1-2% on. This cycling of diets actually reduces your metabolism. You'd be surprised that many people who might weigh twice as much as you do, don't in fact eat twice the calories.

What of those that diet and keep the weight off? About 10% of people have genetics that mean the body does not react by increasing hunger and reducing fullness hormones to the same extent. They are the 10% you will find at the front of slimming magazines or on your local gym's website. Thousands of years ago these people would be less likely to survive famines, but that's not exactly a down side in the modern world.

Because people don't understand how their bodies work, they think that they are morally flawed when they go through this diet cycle. That they can't stick to a healthy diet with reduced calories because they just don't have enough willpower. This feeds into low self esteem which is something that - you are right - something like counselling might help with. Low self esteem can lead to eating an unhealthier junk diet as it gives you short term dopamine. However, counselling is about €70 a session, and it's success will depend on how well trained your counsellor is in this kind of area, and how deeply ingrained some of your beliefs are. In the meantime, you remain overweight or obese which for most people is disastrous for their health.

A combination of medication and counselling is likely the ideal solution.

I understand that I'm leaving out some of the other factors that are contributors to the obesity crisis i.e. ultra processed foods and sedentary lifestyles. Doing your best to eat less processed food and getting more active will, of course, help you lose weight and keep it off. The good thing about the medication is that it gives you the space to try and make those changes to your diet without the white-knuckling that happens when you "come off" junk food. When you lose some weight, it makes exercise so much easier. Not least because the head space that is freed up from constantly thinking about food and dieting means you can actually think about other things.

It is quite a mindset change - to come away from thinking that overweight people are just lazy, cheating on diets or are just not motivated enough to change their ways. In the 1300's the Pope made gluttony a sin during a time of regular famines. Ever since then, being fat has been seen as sinning. Whereas the only way to purge your sin was to do the penance of restriction and exercise. It might be why people bristle so much at medication fixing the issue - you haven't paid your penance as such. It's time we moved away from that.

60% of the population are overweight or obese. There aren't enough counsellors. And even if there were, I doubt 60% of the population are suppressing some kind of pandora's box of unexplored trauma. Nor would 60% of the population have a spare thousand euro or three to attend a counsellor over say, a six month period.

For most people, I think, it's a combination of things. A busy lifestyle which has led you to grab convenient short term solutions full of processed crap (that didn't exist 30-40 years ago) that prevents your natural fullness hormones from kicking in. That has led to a weight gain, that you have tried to lose through a restrictive calorie diet without really looking at the quality of the food you were eating or amending bad habits.

That has led to the diet-binge cycle which over the years just makes the weight creep up and up and metabolism reducing. Of course there may be undiagnosed physical or psychological issues that aren't helping (PCOS, thyroid, depression, ADHD and autism to name a few all effect diet choices and ability to lose weight in different ways) and that's where GPs should really be stepping in. The problem is, GPs aren't trained in this stuff at all. Most GPs will not test you for any of the above if you come in saying you'd like to lose weight. My own GP gave me a HSE healthy lifestyle leaflet and a Slimming World leaflet when I asked about wanting to lose weight. I've since been privately diagnosed with ADHD.

And that's not to say that there may be other issues at play in disordered eating. Perhaps when you were younger, treats were used as a fix all for every difficult or stressful situation. Or maybe it was the opposite, treats were never allowed and therefore eating them now gives you a sense of autonomy or independence. Believe me when I say that people who are overweight or obese who have dieted a number of times in the past have done a lot of the "work" in exploring how they might have arrived at where they have arrived.

As to your point "I can't help but disagree with this extreme analogy. My take is that significant psychological factors contribute to insufficient willpower or motivation to 'push through' at this uncomfortable physiological point.".

I don't blame you for having this viewpoint. It was my own viewpoint for a very long time. The general consensus when breaking any bad habit or establishing a good one is that if you just persevere, the bad habit will be broken and things will get easier. The brain circuitry will rewire and you can carry on with the good habit. Take giving up smoking or learning an instrument for example. It is a massive mindset change for the general population to understand that it isn't just a case of persevering with a reduced calorie diet. I'm not talking out of my hat here - there are a large number of scientific studies proving it. If you want to read further:

• Here is a good recent meta-analysis on the topic of long term changes in ghrelin following weight loss through calorie-restriction, exercise or both
  https://www.nature.com/articles/s41366-025-01726-4#:~:text=Two%20systematic%20reviews%20have%20assessed,address%20the%20differences%20among%20interventions.
• This is the landmark paper published in 2018 that first explored the effect of changes in hormones following weight loss on long term weight maintenance:
  https://pmc.ncbi.nlm.nih.gov/articles/PMC5764193/

The problem with supervised diet management is that someone has to do the supervising. Who is going to do that? And for how long? It's a bit like handing a drowning person a book on how to swim, when they need a lifebuoy. Medication is that, the lifebuoy. Then we can look at all the other things we need to change in the medium to long term. Ultra processed food, food education in youth, access and time to exercise, parenting techniques, eradicating diet culture etc etc etc.

Delighted to hear your progress Glen, and the fact that you are getting such good results from the 2.5mg dose. Have you had any side effects? Have you noticed any reduction in cravings (if that was something you struggled with)?