Losing weight can be difficult enough. Keeping it off can be harder. But when biology, hormones and environment are part of the picture, perhaps willpower is not the whole story.
Rethinking how we treat obesity
For years, weight loss has often been reduced to a simple formula: eat less, move more and have enough willpower to stick to it. But for people who have spent years trying to lose weight, only to see the kilogrammes return, the reality can be far more complicated.
According to Dr Lavanya Narayanan, Consultant Internal Medicine Physician with a special interest in diabetes care, obesity is not simply a matter of discipline. It is a chronic disease, driven by an interplay of biological, genetic, hormonal, behavioural and environmental factors.
And recognising that difference could change not only how patients see themselves, but also how doctors approach their care.
Dr Lavanya, who leads the Take Charge Programme by Novo Nordisk Pharma (Malaysia) Sdn Bhd, said treating obesity as a chronic condition meant moving away from the idea that a person’s weight was the result of a single failed diet or a lack of effort.
“Obesity meets the clinical definition of a chronic disease: it is persistent, tends to relapse, and is driven by a complex interaction of biological, genetic, hormonal, behavioural and environmental factors rather than a simple lack of discipline,” she said. That understanding has practical consequences.
Instead of a one-off conversation about eating less and exercising more, obesity care should involve ongoing and individualised support — looking not only at weight, but also at a person’s overall metabolic health, sleep, stress, medications and other factors that may affect their ability to manage their weight.
It also means treating weight regain differently. Rather than seeing it as a personal failure, doctors can recognise it as part of the nature of a chronic condition.
When the body fights back
Anyone who has successfully lost weight only to regain it may be familiar with the frustration that follows. The diet worked. The exercise was done. The weight came down, but somehow, it came back.
Dr Lavanya explained that the body itself plays a role in this process.
“When someone loses weight, the body responds with physiological adaptations designed to defend its previous weight,” she said.
Hunger-signalling hormones can increase, while energy expenditure typically falls more than would be expected simply from the weight lost. These changes can persist even after weight loss has occurred, making maintaining weight loss a different challenge from losing it in the first place.
This is also why weight regain should not automatically be interpreted as someone giving up. In fact, Dr Lavanya said the pattern has also been observed following newer pharmacological treatments for obesity.
In a follow-up study of people who had lost weight while taking semaglutide, most regained a substantial portion of the weight within a year after stopping treatment, alongside a return of related metabolic markers.
The lesson, she said, is not that treatment does not work, but that obesity requires long-term management.
“Weight regain reflects biology, not failure,” she added.
That philosophy is reflected in the Take Charge Programme, where follow-up continues beyond the initial weight-loss phase.
Not just about hunger
More than hunger, the term “food noise” has become a common term around obesity. It is used to describe persistent or intrusive thoughts about food, cravings and being preoccupied with eating.
For some people, thinking about food can feel almost constant — even when they are not physically hungry. Dr Lavanya revealed that the experience reflects real biology.
Appetite is regulated by a network involving gut hormones and brain circuits, particularly areas involved in hunger, fullness and the reward associated with food.
For some individuals, these circuits may be more reactive, causing thoughts about food to intrude more often and making them harder to dismiss.
“It’s better understood as the brain assigning food a persistently high priority in a person’s attention,” she said.
The science surrounding “food noise” is still developing, and researchers are working to standardise how the phenomenon is measured and understood clinically. But giving patients a biological explanation for what they are experiencing can itself be meaningful.
For someone who has spent years wondering why they cannot simply “control themselves”, understanding that appetite and food-related thoughts are influenced by biology can help remove some of the shame surrounding eating behaviour.
Same effort, different result
One of the most common questions in obesity care is also one of the simplest: Why can two people eat and exercise in similar ways, yet have completely different outcomes? Genetics is part of the answer.
Genome-wide studies have identified hundreds of genetic variants associated with body weight, while twin studies suggest that genetics account for a substantial proportion of variation in body mass index between individuals.
Hormonal signals regulating hunger and energy expenditure also differ between people. So does the body’s response to weight loss.
This means two people can live in the same environment, eat similar food and follow similar exercise routines, yet experience very different levels of hunger, appetite regulation and metabolic adaptation.
Environment remains important, but it interacts with biology rather than simply overriding it. That is why Dr Lavanya believes obesity treatment needs to be individualised.
“What works well for one person’s biology may simply not be enough for another’s, regardless of effort,” she said.
It is also why the Take Charge Programme does not rely on a generic diet sheet.
Instead, its multidisciplinary approach brings together physicians, dietitians and exercise coaches, with behavioural specialists involved where appropriate, to develop care around the individual’s circumstances.
Where medication fits in
The growing popularity of newer obesity medications has also brought a different debate: whether medication represents an “easy way out”. Dr Lavanya said that framing overlooks what these treatments are designed to do.
Newer medications, including GLP-1 receptor agonists, act on gut-hormone pathways that influence more than hunger alone. They can slow gastric emptying and act on brain regions involved in hunger, reward and energy balance.
This may explain why some patients describe not only feeling less physically hungry, but also experiencing fewer preoccupying thoughts about food. However, medication does not build habits on its own.
“The medication changes the biological backdrop; it doesn’t do the work of building new habits,” she said. That work still involves nutrition, physical activity and behavioural change.
Current clinical guidelines support considering pharmacotherapy as one option based on a patient’s overall health profile and conditions such as type 2 diabetes, fatty liver disease, obstructive sleep apnoea, hypertension or cardiovascular risk.
It is not necessarily something that should only be considered after every lifestyle attempt has failed.
At the same time, Dr Lavanya stressed that medication decisions should not be made separately from the rest of a person’s care.
Within Take Charge, patients receive nutrition guidance, physical activity and behavioural support as the foundation of their care, regardless of whether medication becomes part of their treatment.
“When medication is part of someone’s plan, it supports that lifestyle work; it doesn’t replace the need for it,” she disclosed.
The muscle behind weight loss
There is another part of weight management that can easily be overlooked when the focus is simply on the number on the weighing scale: muscle. Not all weight loss is equal.
A person may see the number on the scale fall, but if a meaningful proportion of that loss comes from lean mass, there can be consequences for strength, mobility and metabolic health.
Skeletal muscle plays an important role in glucose disposal and insulin sensitivity, as well as physical strength and mobility. This becomes particularly important as people age.
Dr Lavanya said this is why resistance exercise and adequate protein intake should form part of a structured weight-loss plan.
Evidence from a systematic review and meta-analysis found that combining resistance exercise with dietary weight loss resulted in better preservation of muscle mass and cardiometabolic outcomes compared with diet alone.
A randomised trial also found that a higher-protein diet combined with resistance exercise helped preserve fat-free mass during weight loss among older adults with overweight or obesity.
In the Take Charge Programme, exercise professionals therefore do more than hand patients a list of exercises.
They guide patients through structured sessions, teaching them how to perform resistance training safely and effectively before progressively stepping back as they become more confident.
The goal, Dr Lavanya said, is functional strength for life — not simply a better number on a body-composition scale.
Removing shame from the consultation room
Perhaps one of the biggest changes needed in obesity care has little to do with medication at all. It is the way people talk about weight.
“Shame has never helped anyone lose weight, but it has kept many people from seeking the help they need,” Dr Lavanya said.
Weight stigma can affect both physical and mental health and may make people less likely to seek or receive appropriate care.
For healthcare professionals, this means being more thoughtful about how weight is discussed. It can mean asking permission before raising the subject, avoiding language that implies blame and looking at health measures beyond the number on the scale.
It also means allowing patients to speak honestly about experiences such as food cravings, emotional eating and weight regain without immediately feeling judged.
Within Take Charge, Dr Lavanya said the approach is to lead with curiosity rather than correction. That small shift can change the conversation, she further opined.
From being told what to do to understanding why
Ultimately, Dr Lavanya believes long-term obesity care should be about more than giving people instructions. It should empower them to understand their own bodies.
Patient empowerment, she said, means giving people the information and tools to recognise their own health patterns and make informed decisions rather than simply telling them what to do.
She draws a parallel with diabetes care, where continuous glucose monitoring can give patients real-time, personalised information that they can act upon rather than relying solely on periodic measurements taken during clinical visits.
The same principle is built into the Take Charge Programme, where personalised information such as glucose patterns and activity trends can be shared with patients and discussed together with their physician, dietitian and coach.
The aim is not for someone to follow a plan indefinitely because they have been told to. It is for them to understand their own physiology well enough to make informed decisions independently.
For Dr Lavanya, that is the real meaning of taking charge.
A bigger conversation for Malaysia
The need for this shift extends beyond individual patients. Malaysia’s own health data points to a substantial burden of overweight and obesity among adults, alongside conditions such as abdominal obesity, diabetes, hypertension and high cholesterol.
Addressing obesity at population level therefore requires more than repeating the familiar message of “diet and exercise”.
Dr Lavanya believes healthcare needs to expand access to structured, multidisciplinary obesity care beyond specialist clinics, while healthcare professionals need better training in discussing weight without reinforcing stigma.
At the same time, public conversations need to move away from reducing obesity to willpower alone. Biology matters. So do the environment, behaviour and access to care.
A person struggling with their weight does not necessarily need another reminder that they should try harder. They may need to understand why their body responds the way it does, what is working against them, and what support is available.
Because when obesity is treated as a chronic disease rather than a character flaw, the conversation changes — from blame to management, from shame to understanding, and from a single weight-loss attempt to long-term health.
