Weight Loss
Weight Loss
Weight Loss
The overriding principle of weight loss is that energy intake need to rapidly lose weight (e.g. prior to surgery). The
needs to be less than energy expenditure; there is no diet must be nutritionally complete and followed for a
consistent evidence that any one calorie-restricted diet is maximum of 12 weeks (continuously or intermittently),
better than another at achieving weight loss and patients should receive ongoing clinical support.
The two most important factors when considering the Patients should then switch to a maintenance weight loss
benefit of a dietary regimen are: programme.
1. Is the diet healthy, i.e. balanced, nutritious and energy Pharmacological interventions may be considered only after
appropriate? dietary, exercise and behavioural approaches have been
2. Can the diet be maintained long-term? initiated and evaluated for people who are obese or as an
adjunct to diet and lifestyle interventions, after the potential
At least 2.5 hours of moderate intensity physical activity per harms and benefits of treatment have been reviewed
week should be included in all weight loss interventions Bariatric surgery is an effective weight loss intervention
Contrary to popular belief, rapid weight loss is not that is publicly funded for eligible people according to a
associated with an increased risk of weight regain national scoring system. It should be considered for people
compared to gradual weight loss who have not achieved or maintained adequate weight
Very low-calorie diets (< 800 kcal/d) should only be loss, despite engaging with all appropriate non-surgical
considered for people who are obese and have a clinical interventions.
Rapid weight loss is not associated with an increased risk Contact details for local dietitians are available from:
of weight regain dietitians.org.nz
Rapid weight loss, e.g. a 10% reduction in body weight over
five weeks, is associated with the same risk of weight regain Dietary supplements: no evidence of effectiveness and
after nine months, compared to a 10% reduction in body may cause adverse effects
weight over three months.9 Therefore, even though diets that Advise people against using dietary supplements, e.g.
begin with significant calorie restriction and rapid weight loss amarasate, garcinia and other botanicals, for weight loss
may not be sustainable long-term, there is no evidence they as there is no evidence of benefit, often the safety has not
are any less successful than those involving more gradual been established and they may interact with medicines.
changes, and no more likely to cause a relapse into unhealthy Supplements may be unaffordable for many patients and can
behaviours. be associated with adverse effects such as liver failure, colitis
and gastrointestinal irritation.23 Some supplements contain
Simply advising people to lose weight makes them more caffeine or capsaicinoids that may increase energy expenditure
likely to try to promote weight loss, but can result in tachycardia or
Although it can be a confronting topic, health professionals arrhythmias, which is problematic in people with pre-existing
(including doctors, dietitians, nurses and pharmacists) should cardiac conditions.23
raise the issue of weight loss if a person is likely to benefit Similarly, there is no conclusive evidence that herbal
from a reduction in body weight. A meta-analysis of 12 studies preparations, slimming teas or high fibre tablets as appetite
Mediterranean Three strategies: A substantial amount of supporting Serving sizes are not specified and
1. Increased consumption of short and long-term evidence, it can be difficult to estimate calorie
www.mayoclinic.org/
omega-3 fats from fish and plant including a lower risk of CVD events, intake.
healthy-lifestyle/
sources reduced triglycerides, a reduced Iron intake may be insufficient, and
nutrition-and-healthy- risk of diabetes, lower HbA1c and
eating/in-depth/ 2. Substitution of saturated and supplementation may be required.
reduced circulation of inflammatory
mediterranean-diet/ trans fats for non-hydrogenated markers12,13
art-20047801 unsaturated fats
(Recommended by the 3. Consumption of a diet high in
Ministry of Health) fruit, vegetables and whole
grains to increase fibre and
antioxidant intakes and
consumption of very few
products made from refined
grains
Vegetables and fruit are central,
monounsaturated fats are
prominent, sourced mainly from
olive oil. Includes cereals, nuts and
legumes, a moderate amount of
poultry, fish and dairy products and
little to no red meat.
Modified macronutrient
Low fat, e.g. Dietary Includes vegetables, fruits, fish, nuts Associated with lower blood Serving sizes are not specified and
approach to stop and low-fat dairy products that are pressure and a reduced risk of CVD it can be difficult to estimate calorie
naturally low in sodium. Red meat and type 2 diabetes, and improved intake
hypertension (DASH)
may be eaten in moderation. glycaemic control and blood lipid
www.mayoclinic.org/ profile.12
healthy-lifestyle/nutrition- Although not intended as a weight
and-healthy-eating/ loss programme, weight loss may
in-depth/dash-diet/ result as the diet facilitates healthier
art-20048456 meal and snack choices.
www.diabetes.co.uk/diet/
dash-diet.html
(Recommended by the
Ministry of Health)
Low (and very low) Low carbohydrate diets Associated with reductions in blood Fibre and micronutrient consumption
carbohydrate*, e.g. contain ≤ 40% of total energy pressure, triglyceride levels, HbA1c, may be inadequate, consumption of
from carbohydrates. Very low and insulin resistance.14, 15 saturated fat may be excessive.
Atkins, ketogenic†
carbohydrate diets contain < 20% Ketogenesis may cause a reduction High LDL-C as a result of ketogenic
www.mayoclinic.org/ (20 – 60 g/day).5 in appetite.13 diets may compromise artery function
healthy-lifestyle/ Red meat, poultry, fish, shellfish and worsen heart disease.16
weight-loss/in-depth/ and eggs are the primary source of
low-carb-diet/ Initial adverse effects include low
nutrition. energy levels, “brain fog”, increased
art-20045831
The saturated fat content may hunger, sleep problems, nausea,
(Very low carbohydrate be particularly high in versions digestive discomfort, bad breath and
[ketogenic] diets are not marketed as ketogenic. poor exercise performance.
recommended by the Hard to sustain in the long term and
Ministry of Health) most of the initial weight loss seen is
often associated with fluid losses.16
Paleo Focuses on foods theoretically Includes some patterns of Only a few small studies of short
eaten during early human evolution, behaviour known to be beneficial, duration have been conducted with
www.mayoclinic.org/healthy-
e.g. lean meat, fish, vegetables, e.g. drinking water, limiting refined mixed effects on weight, HbA1c and
lifestyle/nutrition-and-healthy-
eggs, nuts and berries, and avoids sugar. lipids.15
eating/in-depth/paleo-diet/ grains, dairy, salt, refined fats,
art-20111182 Requires the elimination of two whole
sugars and processed foods. food groups (dairy and grains). There
(Paleo diets are not recommended Often lower in carbohydrate, higher is a risk of nutrient inadequacy (e.g.
by the Ministry of Health) in protein and moderate to high fibre, calcium, iron and vitamin D) and
in fat; however, the macronutrient it may be difficult to follow. Ensuring
profile can differ substantially adequate calcium is of particular
depending on the palaeolithic concern, particularly for those at risk of
culture/region inspiring the specific osteoporosis.17
paleo diet.
* It is thought that these patterns of eating shift the body away from glucose as a source of energy and towards fatty acids and fatty-acid derived ketones,
at the same time fat storage is reduced 22
† Ketogenic diets are very low in carbohydrate and high in fat
Vegetarian or vegan Those who follow plant-based diets Vegetarian diets, including vegan Requires calorie restriction to be
are categorised as: diets, are associated with improved effective for weight loss.
www.mayoclinic.org/
Lacto-ovo vegetarian: eat dairy cardiometabolic risk factors, and a May include high amounts of saturated
healthy-lifestyle/nutrition-
foods and eggs but not meat, reduced risk of type 2 diabetes and fats, e.g. coconut oil, and processed
and-healthy-eating/ CVD.12
poultry or seafood foods high in calories, sugar and
in-depth/vegetarian-diet/
Ovo-vegetarian: include eggs sodium.
art-20046446
but avoid all other animal foods,
Vegan regimens may be low in iron,
www.bda.uk.com/ including dairy
vitamin B12, calcium and iodine and
resource/vegan-diet- Lacto-vegetarian: eat dairy foods supplementation may be required.
healthier-way.html but exclude eggs, meat, poultry
and seafood
Vegan: exclude all animal
products including dairy, eggs,
and sometimes honey
Very low energy* Typically used for rapid weight loss Reductions in BMI, blood pressure Hard to sustain and should generally
over 8 to 12 weeks prior to a weight and triglycerides can lead to long- only be used for short periods (<
www.nhs.uk/live-well/
loss maintenance programme or if term weight management, reduced 12 weeks), ideally under medical
healthy-weight/
there is clinical need to lose weight CVD risk and obesity related supervision, before switching to a
very-low-calorie-diets/ rapidly (e.g. prior to surgery).19 co-morbidities (e.g. diabetes).5 maintenance diet. No guidance on
Energy intake is usually < 3350 kJ/ May cause a reduction in appetite.20 food selection is provided; education
day (< 800 kcal/d).19 may be required to ensure healthy
Food usually replaced with a options are chosen during the weight
nutritionally balanced product (e.g. maintenance phase.
shake, soup, bar) with high protein Not appropriate for many people, e.g.
content to minimise the loss of children, pregnant women, people
lean tissue, supplemented with aged over 65 years, those with eGFR
vitamins, minerals, electrolytes and < 30 mL/min/1.73m2 or recent acute
fatty acids. coronary syndrome..5
The reduced energy intake may cause
transient adverse effects including
alopecia, tiredness, dizziness and cold
intolerance.
Regular follow ups are required which
may not be achievable for some
people or able to be offered by some
clinics; follow-up by phone may be an
appropriate solution in some cases.
Intermittent fasting* A pattern of eating that cycles Intermittent fasting is as effective Little is known about the long-term
between energy restriction and as a continuous energy restricted risks and benefits.
www.hsph.harvard.edu/
non-fasting. The most common is dietary regimen in terms of weight It is not known what the optimal
nutritionsource/healthy-weight/
the 5:2 dietary regimen where a loss.5 However, some people may timing of fasting or level of calorie
diet-reviews/intermittent-fasting/ normal calorie intake of healthy find intermittent fasting easier to restriction is to achieve maximal weight
sciencebasedmedicine.org/ food is maintained for five days per adhere to rather than reducing the loss.
intermittent-fasting/ week and substantially less eaten amount of food they eat every day.
on two days, e.g. 2100 – 2500 kJ/ Furthermore, with time restricted Some concerns that people may
day (500 – 600 kcal).5 eating, the focus is on when to eat, consume excess calories on the
not on what to eat. non-fasting days, however, studies
Time-restricted eating is another to date have not found this to be the
type of intermittent fasting that case compared to other weight loss
involves fasting for at least 12 hours methods.
every 24 hours, e.g. by abstaining
from food from 7 pm – 7 am. People with diabetes who take insulin
or sulfonylureas are at increased risk
There is no compelling evidence to of hypoglycaemia on fasting days.21
support other types of short-term Requires planning and frequent
“fasts”, e.g. the cabbage soup diet, monitoring to ensure appropriate
for long-term weight loss; many of dose adjustment on fasting days to
these diets involve extremely low reduce this risk.21 Not recommended
caloric intake, and people often for people with type 1 diabetes. Also
regain weight once a normal diet is not suitable for adolescents or during
resumed. pregnancy or breastfeeding.
Mechanism of
Medicine Class Evidence Notes
action
Liraglutide Glucagon-like Reduces appetite Liraglutide, 3 mg Administered as a once daily subcutaneous injection,
(injectable) peptide 1 (GLP-1) and increases satiety daily, for 56 weeks starting at a dose of 600 micrograms, daily, and
receptor agonist* alongside healthy titrating upwards to a maintenance dose of 3 mg,
diet and physical daily.
activity achieved an Generally well-tolerated; common adverse effects
8% weight reduction include gastrointestinal disturbance, e.g. nausea,
and improvements constipation or diarrhoea.
in systolic blood Patients often regain weight over time, it is therefore
pressure, lipid recommended to continue taking this medicine for
profiles, HbA1c and at least 12 months and to continue with lifestyle
fasting glucose changes to maintain weight loss in people who
levels33 respond.34
Does not increase the incidence of CVD in people
with obesity and type 2 diabetes; provides renal
protection in people with type 2 diabetes.33
Cost of treatment may be prohibitive for many people.
Naltrexone Opioid receptor Reduces appetite Mean weight loss Generally well-tolerated, but contraindicated in
+ bupropion antagonist and increases in participants some patient groups, e.g. those with current seizure
(oral) (naltrexone) energy expenditure; who responded disorder or a history of seizures, bipolar, opiate
Selective controls food to treatment† of dependence or withdrawal. Increased risk of serotonin
noradrenaline cravings and approximately 12% syndrome when bupropion is taken with other
and dopamine modifies eating at week 56; 85% of serotonergic medicines, e.g. a SSRI.
re-uptake inhibitor behaviours these participants Nausea is a common adverse effect; it is usually
(bupropion) achieved weight transient and slow dose titration may help to manage
loss of at least 5% at this. Patients can develop elevated heart rate or blood
week 5635 pressure and these should be monitored at baseline
and then at regular intervals.36
If weight loss of at least 5% of initial body weight has
not been achieved after 16 weeks, treatment should
be discontinued.
Phentermine Dopaminergic Appetite Limited trials Indicated for short-term use only, i.e. < 3 months.
(oral) agonist suppressant assessing Contraindications include cardiac abnormalities and
phentermine as hypertension.32
a monotherapy; May have addictive potential (as it is a
15 – 40 mg induced sympathomimetic); be alert for signs of dependence.
weight loss of 3.6 –
4.5 kg at six months
without increasing
CVD or death37
Orlistat (oral) Selective pancreatic Reduces fat Modest weight loss Low-fat diet required to avoid excessive fatty or oily
lipase inhibitor digestion and (2 – 3% of total body stools.
absorption, which is weight after one Adverse effects can be significant, e.g. faecal urgency,
excreted in the stool year)33, 37 flatulence, cramps, bloating and impaired absorption
of fat-soluble vitamins. These symptoms may indicate
that the patient is eating too much fat, which may
motivate them to reduce their intake.32
Slowly titrating the dose or adding psyllium fibre to the
diet may reduce gastrointestinal adverse effects.38
* Dulaglutide, which is also a GLP-1 receptor agonist, promotes greater reductions in HbA1c than liraglutide, however, the extent of weight loss and
cardiovascular protection are similar.39 Patients may prefer to take dulaglutide because of its once weekly injectable dosing regimen, rather than the
daily dosing and titration required with liraglutide treatment. People with type 2 diabetes may be eligible for funded dulaglutide treatment and some
people who do not have diabetes may benefit from off label and unfunded use of dulaglutide for weight loss. Further information on dulaglutide is
available from: bpac.org.nz/2021/diabetes.aspx
† Defined as ≥ 5% weight loss at week 16 of treatment34
References
1. Ministry of Health. Annual update of key results 2020/21: New Zealand Health
Survey. Available from: https://www.health.govt.nz/publication/annual-
update-key-results-2020-21-new-zealand-health-survey (Accessed Mar, 2022)
2. Theodore R, McLean R, TeMorenga L. Challenges to addressing obesity for
Māori in Aotearoa/New Zealand. Aust N Z J Public Health 2015;39:509–12.
doi:10.1111/1753-6405.12418
3. Misra A. Ethnic-specific criteria for classification of body mass index: a
perspective for Asian Indians and American Diabetes Association position
statement. Diabetes Technol Ther 2015;17:667–71. doi:10.1089/dia.2015.0007