The Obesity Epidemic
Currently, 42% of U.S. adults and 20% of children are obese. When I started presenting at national conferences 15 years ago, these numbers were 10% lower. This is a tragedy–there is no other way to put it. It’s time to address the real issues here, and there are so many!
Technology has made it so we move so much less than before. Wearables, although fun and exciting have not shown to make a dent in this crisis. I would argue that the over-monitoring of individuals has actually negatively impacted their health. Many of my patients are confused by the data and get very stressed if something does not read exactly as they think it should, affecting sleep, pulse, blood pressure, and more. Technology has not been a friend to the obesity crisis no matter how you look at it.
As many know, the movement piece became much worse during COVID with the closing of gyms, and the terrible fear everyone had of going anywhere, even into their own backyards. I saw children at my office who gained as much as 80 pounds during that time. Adults seemed to do a little better at 30-50 pounds, but equally devastating.
The situation with our food is even worse. One of my early mentors used to say to me, “Eat local and eat in season.” What wise words. This crisis could be easily solved if we cooked our food, sat down for meals as a family, ate local produce, and ate in season. The “middle aisle” of the grocery store is full of mostly processed, shelf-ready, junk. Sorry, but that is the brutal truth. We must get back to living as our grandparents did. Back in the times before fast food restaurants were on every corner, and local produce was sold on street corners by the farmers who grew it. As long as we demand the bad stuff, it will be supplied.
We need to change our ways as Americans, one step at a time. This is a conversation for another day, but hopefully, now I have your attention.
The 4 Pillars of Weight Loss
As obesity medicine physicians, we are trained to address 4 key areas (or pillars) that affect weight. When each is addressed appropriately, diseases are not treated but reversed! It’s an honor to help a patient lose 100+ pounds (without surgery!) and keep it off long-term. It is even more exciting when they can put all the money they used to pay for their former medications into buying home exercise equipment, a bike, learning a new hobby, or planting a garden! I love what we do – and here’s how we do it.
Pillar #1: Nutrition
The first rule to the nutrition pillar is easy: “The diet that works is the diet you stick to.”
What does that actually mean? Previous success usually dictates future success. If a patient did well on a keto diet, likes that food, and can afford it (that has to be part of the equation too), then we consider a version of that plan to follow. There is no perfect diet, but there can be a “better diet” for a particular person.
At our practice, we try to make it as easy as possible. The less guesswork the patient has, the better they do. To that end, we use a lot of meal replacements. We’ll either replace all their meals, taking food completely out of the equation, or replace most meals leaving only one for them to prepare (usually dinner).
Keep in mind that over-the-counter protein shakes and bars are not the same as medical-grade meal replacements that are tested in clinical trials and perfectly balanced from an electrolyte and vitamin standpoint. They provide the appropriate protein needs to maintain muscle as a patient loses weight. Patients who are on full meal replacements are seen weekly at our office as disease reversal happens fast, and medications need to be removed quickly. Partial meal replacements require less monitoring (usually seen every 2-4 weeks) and can be tried safely by just about anyone. A typical plan would be 2 shakes, 2 bars, and a lean and green dinner.
Although it might be hard to believe, people on meal replacements for the weight loss phase actually do better in maintenance, because they already have a good food rhythm going, and they will usually keep one or two high-protein products on board. Meal replacements can also be incorporated into other plans including keto and intermittent fasting, both of which we encourage at our practice.
Weight Loss Diet Plans
How do you know what is the best diet plan for you? Here are some summary thoughts that might help you decide. These are the most popular supported by our office.
- Keto/Atkins: This is a good plan for people who like animal protein. If you are a vegetarian or vegan, don’t even bother. In my experience, it is too hard to meet the protein requirements needed with plant-based protein. If you are a carb addict, you must be patient in the first couple of weeks of keto. You may experience withdrawal, but once you are on the other side, you won’t crave carbs and sweets as long as you keep away from them.
- Intermittent Fasting: If you follow us on Instagram, you know this is what I do most of the time. Intermittent fasting is great for all cancer survivors like me because it promotes remission, causing cells to go through “apoptosis” or programmed cell death which is what cancer cells do not do. It also cleans up inflammation and reduces free radicals, decreasing joint pain and making you feel better in general. The most popular intermittent fasting is 16:8 which means you eat for 8 hours, and fast for 16. For example, drink black coffee or tea in the am, and eat from 12 pm – 8 pm. If you think you can skip breakfast and stop eating at a specific time at night (including alcohol) this is a great plan for you.
- Primal/Paleo: I follow a primal plan when I am doing a calorie-restricted meal plan. Primal avoids sugar and starchy carbs like the whites (bread, potatoes, rice, pasta), but allows healthy complex carbs like fruits and veggies. Paleo removes dairy as well. These plans are great for maintenance because they remove most people’s trigger foods.
- Vegetarian/Vegan: If you want to switch to either of these plans for personal, political, or religious reasons, go for it! But be very careful to learn how to do these properly. I can’t tell you how many times I’ve had patients try either of these plans and turn into full-on “carbivores.” Carbohydrates are easy to find, can be addicting, and do not support muscle mass. You must learn to maximize protein through plants if you decide to try these plans. You must also replace your B-12 as you will most likely be deficient.
Pillar #2: Exercise
There is something called “the paradox of exercise” in the weight loss world. If you have not heard of it, you might be blown away. When you are trying to lose weight, rigorous exercise is NOT your friend. Why do I say this? Because exercise will always increase your hunger. It may not happen immediately, or it may not be until the following day, but it will happen.
Since 90-95% of weight loss is related to the food you consume, eating more food will often override the calories burned, slowing down weight loss and making you feel frustrated. My advice is to always titrate your exercise to your hunger. If you are not overeating on your plan, you are good. If you are, you need to cut back on exercise. That being said, when you get to your goal, exercise becomes a very important piece to help you stay there.
At our clinic, we focus initially on increasing your NEAT or non-exercise activity thermogenesis. This is the movement you do during the day without thinking about it. Examples of NEAT include walking while talking on the phone, getting a standing or walking desk, parking further away, or taking the stairs instead of the elevator. As you get closer to your weight loss goal, we increase exercise with the overall goal of 60-90 minutes per day by maintenance. That sounds like a lot, I know, but it’s what has been shown to override metabolic adaptation that tries to bring you back to your set point weight.
Pillar #3: Behavioral Modification
In this day and age of everyone wanting a quick fix through injectable weight loss meds, behavioral eating is often overlooked. But honestly, this is a huge part of the problem for those who say “I can’t take these drugs!” Binge eating, fast eating, emotional eating, meal skipping, not sleeping, night eating, eating on the run, or dashboard dining—all of these play a significant role in weight loss and maintenance.
Behavioral Eating Disorders
Let’s review the top 3 behaviors I’m seeing recently and I’ll add some “clinical pearls.”
- Emotional Eating: This is so common right now. The key to addressing emotional eating is to separate the emotion from the unhealthy behavior, which usually involves going for some unhealthy food such as chips, sweets, or other bad-for-you carbs. When we are stressed, our serotonin (the “feel good” hormone) levels drop and we go for the foods that give it back to us–carbs and sweets. I recently shared an Instagram post on this topic and wrote an article to help you work through the process of separating emotion from behavior. An example would be getting a craving and training yourself to leave the house, drink a bottle of water, and go for a short walk instead of giving in. The more you do this, the more it becomes a natural response.
- Binge Eating Disorder (BED): If you are a binge eater, you usually know it. Binge eating involves consuming a large quantity of food (for reasons often not involving hunger) that is usually planned. It may be something you have dealt with since your childhood to create a numbing response or other emotional response. It is commonly followed by regret and self-loathing which can further perpetuate the disease. However, it can be overcome! In addition to the Cognitive Behavioral Therapy described above, binge eating responds to supplements such as Chromium, and medications such as Topiramate (Topamax), Lisdexamfetamine (Vyvanse), and Naltrexone.
- Night Eating Syndrome (NES): NES is increasing lately because many folks are struggling with sleep. With night eating, you wake up and eat in the middle of the night. It can run in families, and the person will often feel like they cannot fall back asleep until they have eaten. The key to NES is sleeping through the night. We often address this with measurements that improve sleep including focusing on sleep hygiene, using supplements like Melatonin or Magnesium, or sometimes medications such as Trazodone as a last resort.
Pillar #4: Medical Management
The medical management piece is what makes the weight loss stick. This is what separates obesity medicine from Weight Watchers, Noom, Nutrisystem, and every other program out there that is based upon chronic failure for revenue. Medical management also sets obesity medicine apart from other medical fields, because it is the only traditional medicine field that focuses on disease reversal! It should get more attention than it does, particularly in this day and age where some medications are in shortage. As a former electrical and computer engineer, I have never understood why being a doctor meant keeping people sick instead of making them better. Okay, done with that rant. For now.
A 5-10% weight loss reverses many chronic diseases including sleep apnea, hypertension, high cholesterol, diabetes, gout, fatty liver, reflux disease, and countless others. As many as 150 conditions are related to obesity, and most can be reversed with weight loss! For this process at MWL, we monitor blood work and vital signs, and the most weight-gaining medications are removed first. This absolutely should be done in conjunction with a medical doctor, but that doesn’t mean that if you lose weight, you can’t contact your provider and ask “What can be removed?”
Weight Loss Medications
In addition, we might add a medication or two to help with hunger and metabolism, or the behavioral conditions above if the behavioral techniques don’t work. Lately, we’ve been hearing a lot about GLP-1 inhibitors such as Ozempic, Wegovy & Mounjaro. They have been a wonderful adjunct to the medical weight loss world, but are NOT the be-all and end-all. It is so important to remember the other three pillars must be implemented with injectables for an individual to lose weight safely and effectively with minimal side effects. These medications are so powerful that you really don’t care about food after a while. This can backfire because we have to eat as humans! The whole “Ozempic Face” narrative I believe, is related to the fact that some providers are not using these medications in combination with a healthy diet and exercise regimen. And some patients are truly not eating at all, looking gaunt and unhealthy.
Some other common medications are the following:
- Topamax (Topiramate)
- Vyvanse (Lisdexamfetamine)
Read more about these medications here.
I hope this article has enlightened you, and helped you to understand that there are four very important pieces needed to lose weight and keep it off. Not one can be neglected. Weight loss is a multi-billion dollar industry that preys on folks who are struggling and looking for the next quick fix. Please don’t fall prey to all the gimmicks, but rather work with a specialist to lose weight, get off your medications, and live life to the fullest! Check out obesitymedicine.org to find an obesity medicine doctor close to you.