A Holistic Multimodality Approach to Weight Management and Body Contouring

Body contouring and weight management is becoming increasingly popular in line with the progressive rise in our overweight population and emergence of more demanding beauty standards. I firmly believe in helping my overweight patients achieve weight reduction and body contouring for the purpose of general health benefits, prevention of secondary health implications as well as supporting body confidence in feeling comfortable with their body shape.

Obesity is a serious health condition in view of its direct link to a number of different illnesses including diabetes, fatty liver disease, high blood pressure as well as psychological effects. As a complex problem its treatment should involve multicomponent interventions such as weight management, behavioural change strategies and lifestyle modifications. Any patient with an increased BMI or waist circumference is identified as having significantly higher risk of future health implications.

Weight management and body contouring often goes hand in hand. Most of my patients who seek these treatments have struggled with weight and body image for a significant portion of their lives, have tried numerous failed methods of losing weight and often present to myself as a last resort. Patients often complain of certain areas of exercise and diet resistance excessive fat tissue which require additional targeted fat reduction treatments. Unfortunately weight loss may lead to loose skin and skin tightening treatments may therefore also be required in some cases.

Patients’ motivation for commencing treatment is often also driven by preparing for a special event such as their wedding or having considered the possible health risks of being overweight as they are getting older. Other patients may have been given a requirement to reduce their weight into the healthy range to reduce the risk of a general anaesthetic or optimise the results for a planned surgical procedure. Regardless of the context, careful patient assessment is vital to ascertain their level of excess body weight, the underlying causes for this and overall associated health risks.

The principle of our multimodality approach includes:

- Initial lifestyle and behavioural modifications including exercise and dietary changes. Methods such as calorie counting and intermittent fasting may be utilised.

- Building sustainable habits with early preparation for maintenance to ensure meaningful results are achieved for longterm benefits.

- Saxenda treatment to support weight reduction in selected patient groups.

- Body contouring to further reduce diet and exercise resistant fat tissue. Cryolipolysis (fat freezing) may be combined with Ultrasound (US) & Radiofrequency (RF) driven fat reduction. Selected patient will also require prophylactic or therapeutic skin tightening using the latter method.

Lifestyle and Behavioural Modifications

All patients who are identified as overweight will initially be recommended to implement some lifestyle changes. These will generally include reducing their calories by 500 kcal per day as well as increasing their weekly exercise.

Barriers to healthy eating habits such as tendencies for emotional eating are explored and behavioural modifications such as the implementation of coping mechanisms are discussed. CBT input is available in-house for selected patients who may require additional support. The ultimate aim is for the patient to amend their lifestyle and relationship to food to a level where they will be able to maintain the modifications long-term once their treatments are completed.

Saxenda (Liraglutide 3mg) injections

Saxenda is a medication with the active substance Liraglutide, a glucagon-like peptide 1 (GLP-1) receptor agonist. It is used for weight management as an adjunct to dietary, activity and behavioural modifications in patients who have been unsuccessful in reaching their target weight or reached a plateau. Saxenda comes in the form of an injection which is self-administered by the patient daily. Saxenda is strictly used in selected patients only. Patients must have an increased BMI (30 or above) or a BMI of 27 or above if they suffer with a weight related medical problem. It is utilised for its appetite and hunger suppression properties and has been shown to be a safe and effective option for selected patients under the supervision and close monitoring of a doctor.

Patient selection is key for a successful outcome on Saxenda. From my experience I have found that the below outlined patient groups are most likely to benefit from Saxenda:

- Patients who are moderately to highly driven by appetite or hunger

- Patients who have a low to moderate motivation by emotional, comfort or stress eating

- Patients who are consuming an excessive daily calorie amount (2000 kcal or above)

- Patients who do not expect “a quick fix” (minimum recommended duration of treatment is 16 weeks)

- Patients who are willing and ready to modify their lifestyle with an acknowledgement and ownership of their actions (rather than the medication itself) leading to weight loss

Naturally a number of other factors such as reduced basal metabolic rate (low metabolism) which may be secondary to fixed causes like menopause or modifiable causes such as a reduced body muscle mass may hinder or delay the patients success, however with persistence these can readily be overcome.

Medical Cryolipolysis

Our Cristal device by ICE Aesthetics utilises the technology of medical Cryolipolyisis (more commonly known as Fat Freezing) to permanently reduce fat cells in localised areas of increased subcutaneous fatty tissue. Any area can be treated with this technology including love handles, bra folds and the submentum (commonly known as the double chin area). These fat folds are treated using a vacuum mediated applicator which crystallises fat cells to approximately-6°C, introducing an environment where the fat cells cannot survive. This triggers a process known as apoptosis (programmed cell death) whereby the fat cells are flushed out the body over a number of weeks.

It is important to note it is only possible to target subcutaneous layers of fat (fat underlying the skin) rather than visceral fat (internal fat surrounding the organs) as the cooling mechanism does not affect tissues beyond this level. Subcutaneous fat is usually the culprit of contributing the most to less desirable body shapes. Having said this, visceral fat is very significant for cardiovascular risk and fortunately is usually the first type of fat tissue to be eliminated by general weight loss.

My preference for the use of Cryolipolysis is to achieve debulking of deep fat tissue in patients with minimal skin laxity as well as significantly enlarged fat folds which are localised and easily “pinchable”.

Radiofrequency (RF) and Ultrasound (US) driven Fat Reduction and Skin Tightening

Our Exilis Ultra 360 device by BTL Aesthetics simultaneously emits RF and US energy to generate heat which triggers apoptosis (programmed cell death) of fat cells thereby achieving permanent reduction of subcutaneous fat. By focusing the energy to an even more superficial level one can also achieve heat provoked stimulation of collagen, elastin and fibroblasts to produce skin tightening.

My preference for the use of US & RF based treatments are either in patients who have intermediate to superficial layers of subcutaneous fat, following Cryolipolysis treatment to tidy up and contour residual fat layers or in any patients who presents with pre-existing skin laxity.

In the latter case, the Exilis may be used prior to Cryolipolysis as a preventative measure to avoid worsening of their skin laxity by “deflating” the fat folds and thereby causing the excess skin tissue to become more visible. The Exilis will often suffice as a stand alone treatment where there is only intermediate to superficial fat tissue or where the area of concern is as more widespread.

Case Study: 49 year old woman who received multimodality weight management and body contouring treatments over 14 weeks.

Case Study

To illustrate the benefits of this multimodality concept a patient of mine has agreed to be featured as a case study. This 49 year old woman presented with increased body weight as well as diet and exercise resistant areas of stubborn fatty tissue on her lower abdomen. She also had uncontrolled hypertension (high blood pressure), high cholesterol levels and a family history of cardiovascular disease.

Her weight and body shape was affecting her confidence and she was also understandably concerned about the health implications of her weight. She had attempted multiple methods of dieting for most of her adult life, including the medication Orlistat and regular exercise with no success.

My assessment revealed that her BMI put her in the Overweight category and in combination with waist circumference she was deemed at High risk of cardiovascular implications. There was a mild emotional component only, lack of restraint and an excessive daily calorie intake was elicited.

The patient was commenced on Saxenda treatment and over a period of 14 weeks she achieved a significant improvement in weight, health and confidence profile. During this period she also underwent 2 sessions of Cristal Cryolipolysis to the lower abdomen to permanently reduce the deep layers of localised excess fat. She subsequently had 4 sessions of Exilis RF and US treatment to achieve intermediate and superficial level fat reduction as well as skin tightening. As illustrated in the before and after photos she obtained a very successful overall result from this combination of treatment and was extremely pleased with her achievements.

I am very hopeful our patient will continue to independently maintain and further improve her weigh and cardiovascular risk factors into the recommended range by utilising the healthy lifestyle habits and foundations laid down during this period of multimodality and holistic treatment.

Case Study Achievements:

- 8 cm reduction in waist circumference

- 1.7 point drop in BMI

- 6.4% of total body weight loss

- Resolution of uncontrolled high blood pressure into the normal range, cessation of the need for blood pressure controlling medications (pre-treatment blood pressure of 172/102 mmHg improved to 115/84 mmHg)

- Fat fold calliper reduction of 22 mm in the lower abdomen

- Improved body confidence

- Improved awareness of healthier lifestyle and behavioural modifications for ongoing independent weight management.