Anyone who has ever tried to lose weight through various diets is familiar with the yo-yo effect. Either the diet does not work at all, or right after the weight comes off it bounces back and starts rising again. As if the body got frightened by the new eating regime and decided to hold on to the weight out of pure spite.

This is called metabolic adaptation, or adaptive thermogenesis, and the essence of the phenomenon is that the rate of metabolism drops more steeply than the weight does. In effect, metabolism freezes itself in place.

The most famous illustration of this is the study of contestants from the American television show The Biggest Loser. Six years after their dramatic weight loss, their metabolism remained suppressed, and their energy expenditure was significantly lower than would have been predicted from their body composition. The adaptation did not let go after a year or two, it held on for years.

In parallel, there is a hormonal assault. Leptin, the fat-tissue hormone that signals satiety to the brain, falls. Ghrelin, the hunger hormone, rises. Satiety hormones decline, the famous GLP-1 among them, along with PYY and cholecystokinin. What you end up with is what the literature calls the energy gap: the body simultaneously wants to eat more and burn less. While you think you are fighting «with the plate», you are in fact at war with an endocrine system that is defending what it has come to consider your norm.

The phrase «just eat less and move more» is, of course, technically true, especially for healthy young people, but for those of us with a long history of weight struggle it is completely useless. It is the equivalent of advising someone to swim across a river while ignoring the current.

SurgeryIs bariatric surgery the perfect answer?

For a long time it was believed that bariatrics worked mechanically: reduce the stomach, less food fits, the person loses weight. Simple and intuitive. And, as is often the case with simple explanations, largely wrong. If it really were that straightforward, sitting on a «bariatric diet» of 150–200 ml per meal would work just as well as the surgery itself. It does not.

Half a century after the first such operations, it became clear that the main player is the change in gut hormones, not the physical restriction of volume. After gastric bypass and sleeve gastrectomy, the secretion of gut hormones shifts dramatically. Food reaches the lower parts of the intestine more quickly, where specialized cells are activated, and the postprandial (after-meal) release of GLP-1 and PYY rises sharply. These are the very satiety hormones whose levels are reduced in people with obesity and are restored after surgery.

In other words, the stomach and small intestine are not merely a pipeline for food. They are powerful endocrine organs, and the surgery rewires their signals.

The proof that it is not merely mechanical is elegant: improvement in carbohydrate metabolism, gains in insulin sensitivity, and even the discontinuation of some diabetes medications often occur before any substantial weight loss. If everything came down to the size of the stomach, this could not happen. The effect is metabolic, not purely restrictive, which is precisely why these operations are nowadays called metabolic surgery.

The scale of the effect is serious. Bariatrics delivers an average loss of 15–30 percent of initial body weight depending on the procedure. In the Swedish Obese Subjects study, a long-term prospective controlled trial, diabetes remission two years after surgery reached 72 percent versus 16 percent in the control group on conventional treatment.

And yet surgical treatment is, unfortunately, not the perfect answer to obesity either.

In that same Swedish study, by the fifteen-year mark diabetes remission had dropped from 72 to roughly 30 percent. In other words, a sizeable share of patients returns to the disease. Weight regain and insufficient weight loss are well-known and widespread problems after surgery.

One of the mechanisms that explains weight regain is the decline of that same postprandial GLP-1 over time. The hormonal rewiring partly reverses itself.

The core problem is this: surgery changes anatomy and physiology, but behavior, lifestyle, the relationship with food, and stress all stay as they were. And so metabolism gradually drifts back.

HypnosisSurgery without a scalpel. The wonder of hypnobariatrics

If the matter is not so much about the stomach itself but about the signals it sends to the brain, a reasonable question arises: could those signals be changed without any cutting?

This is where hypnobariatrics, also known as the virtual gastric band, enters the stage. It is a clinical hypnosis technique that creates in the mind a convincing experience of having actually undergone gastric banding surgery. The person leaves the session with the felt sense that the stomach has become smaller, and starts feeling full on smaller portions. The intriguing part is that the patient is perfectly aware that no surgery has taken place. But the subconscious mind is a terribly literal creature. You told it «the stomach is smaller», so the stomach is smaller, no further questions.

Years ago, after reading an article reporting a 95 percent success rate of the hypnobariatric method, I rushed off to take courses and learn the protocol.

From the standpoint of evidence-based medicine, that 95 percent figure, reprinted by hundreds of websites, is not the result of a controlled trial. It is the practitioner’s own observations of her clients, without a control group, without publication in a peer-reviewed journal. I, for one, believe her. But the fact remains that the only real randomized controlled trial of the virtual gastric band compared it with ordinary relaxation hypnotherapy and found no significant difference in weight loss between the two. The British clinical guidance body NICE does not recommend hypnosis as a standalone treatment for obesity.

And yet I would argue that treating obesity with hypnosis does work. And there really is an evidence base behind it. Hypnosis shows its strength as work with the psychology of eating: with emotional eating, with automatic reactions to stress, with the relationship to food, with motivation. And it works precisely as part of behavioral therapy, amplifying it, rather than as some magical «narrowing of the stomach».

Look closely at what is happening here. Both surgical bariatrics and hypnobariatrics share the same flaw. Both change the volume of food eaten. Neither, on its own, changes habits, the relationship with food, the quality of nutrition, or lifestyle. Surgery rewires anatomy. Hypnosis rewires the sense of satiety. And a person who used to eat in the evenings out of anxiety still wants to eat in the evenings out of anxiety. The fashionable GLP-1 injection is the same story: a wonderful tool, but it changes exactly one aspect, the biochemical one. Stop the injection, and the appetite returns.

No single tool solves the problem of obesity, because obesity is not a problem of a single aspect.

The modelFive aspects of health, or why a stool cannot stand on one leg

Over years of work with chronic pain and metabolic disorders I have arrived at a simple model. Obesity, like most serious health problems, rests on five supports.

Long-term, reliable results come only from working on all five aspects at once. Because weight rests on all five supports at once, and any abandoned support will, sooner or later, bring the others down.