Helping you to reach your healthy weight

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According to the Obesity Medicine Association: “Obesity is defined as a chronic,

progressive, relapsing, multi-factorial, neurobehavioral disease, wherein an increase in body fat promotes adipose tissue dysfunction and abnormal fat mass physical forces, resulting in adverse metabolic, biomechanical, and psychosocial health consequences”

Wow, it is a long definition that is hard to understand at a glance, so let’s break it up:

Chronic: gaining weight doesn’t happen over nights or even weeks, it occurs over months and years. Even consuming just 3.5 calories extra each day, you gain 10 lbs. after 3 years. 

Progressive: gaining mass keeps going on if left unchecked.

Relapsing: this is the frustrating part, many people who lose wight initially, they regain it and finally give up any intervention to lose weight again. The exact cause of regaining weight is not clear, but we have enough information to reduce the risk of regaining weight(relapse), see page/chapter

Multi-factorial: Many different reasons can cause obesity, like 

- Genetics: Less common cause

- Environmental: easy access to junk foods, low price of low-quality foods, holidays with lots of candy, celebrations with lots of pizza, you name it. 

- Stressors: meeting deadlines, piling bills to pay, naughty teenager at home, marital conflicts.

Neurobehavioral: interaction of the brain reward system with our daily choices to eat junk vs healthy foods. 

Abnormal fat mass: accumulation of fat in abdomen, buttock, thigh, upper arms, neck that just because of heavy mass impairs proper mobility and function of different organs in the body, common examples:

-Not able to tie your shoelaces and feeling very winded, this happen when an obese abdomen pushed diaphragm upward and limits your lung capacity to breathe deeply.

-Knee pain and arthritis: When you climb downstairs, four times of body weight is the pressure that impacts keen and pelvic joints, another example is progressive chronic low back pain. 

Adverse metabolic and biochemical effects: Excess fat cells in the body are acting like a metabolic bomb that constantly releasing so many toxic chemicals into the circulation. Those toxic chemicals reaching every single organ and cells in the body and impair their proper function.

Psychosocial health consequences: Many people with obesity struggle to have a positive body image of themselves. Feelings of guilt or being stigmatized as a person with a poor will power or being lazy further inhibits them to commit to a weight loss program. 

There are four pillars of clinical obesity treatment, which are: nutrition, physical activity, behavior, and medication. When combined and personalized, treatment plans that utilize the four pillars help patients lose weight and achieve better overall health.

Nutrition

Effective nutritional interventions are evidence based, promote patient adherence, consider patient preference, and specify the type and quantity of food. A variety of nutritional plans are available and are chosen based on individual needs. Consideration is given to the desired health and metabolic benefits. Nutritional plans need to be continued long-term, although it may be necessary to modify or shift to another approach, particularly if there is weight regain or health changes.

Physical Activity

Physical activity has a favorable effect on metabolic, cardiovascular, mental, and

musculoskeletal health and improves body composition. An increase in physical

activity may promote weight loss, but the effect varies. Research shows that

physical activity is an important component of weight loss maintenance. Physical

activity plans need to be safe and reasonably attainable. The focus is on establishing

a pattern and gradually increasing until the desired benefits are achieved.

Behavior

Implementing and maintaining lifestyle interventions is challenging and most

people require behavioral support. The focus is on gradually replacing unhealthy

behaviors with healthier behaviors. Effective tools include setting small achievable

goals, building on previous success, utilizing self-monitoring tools, encouraging

non-food rewards to reinforce new habits, and minimizing or eliminating

temptations in the environment.

Medications

There are common medications that contribute to weight gain, such as some

antidepressants, blood pressure medications, contraceptives, and insulin. It is

important to identify any medications that promote weight gain and if possible,

transition to medications that do not. FDA approved anti-obesity medications

(AOMs) reduce hunger and increase adherence to nutrition plans. They are most

effective when combined with the other three pillars.

Although obesity was once considered a behavioral problem or a lifestyle choice, science

has shown us that there are many genetic and environmental factors that contribute to

obesity. In 2013, the American Medical Association recognized obesity as a disease. The

accumulation of excess fat tissue impairs physical, metabolic, and psychologic health,

impairs quality of life and shortens lifespan. Given the health consequences of obesity,

it is important to treat it seriously. A weight reduction of 5-10 percent can reduce the

chances of developing numerous health conditions including:

• Atrial fibrillation

• Cerebrovascular accidents (stroke)

• Type 2 diabetes

• Fatty liver disease

• Acid reflux

• High blood pressure

• Osteoarthritis

• High triglycerides

• Asthma

• Obstructive sleep apnea

• Many types of cancer

  Some people believe that having obesity or pre-obesity does not

significantly impact health, but this is not the case. Carrying excess weight

can have significant health consequences. Confusion may stem from terms such as

“metabolically healthy obesity.” These terms are often used to indicate that metabolic

diseases such as diabetes and hypertension are not always present in people with obesity,

and that they are sometimes found in normal weight people. To better understand this,

we need to take a look at what causes the health consequences of obesity. This can be

thought of in two separate but related processes.

“Fat mass disease” is characterized by excessive physical force on body tissues resulting

from body fat. This can cause joint problems, obstructive sleep apnea, and other

problems. There is also “sick fat disease,” which is characterized by a disruption in the

normal hormonal and immune properties of fat tissue. Many people think of body fat

as simply a place in which the body stores extra calories, but this is not its only function.

Body fat also plays an important role in the function of the endocrine and immune

systems. When the function of these systems is disrupted by excess fat, diseases such as

type 2 diabetes and fatty liver disease can develop. Although those with “metabolically

healthy obesity” do not have the metabolic problems associated with “sick fat disease,”

they can still suffer from “fat mass disease” and are at increased risk of developing “sick

fat disease” over the course of their life.

Both “fat mass disease” and “sick fat disease,” can lead to a multitude of health problems.

  Some of the most common are listed below, although it is important to note that there

may be other causes to these problems as well:

• Cardiovascular disease, including heart attacks and strokes

• Heart dysrhythmias

• Blood clots, including pulmonary embolism

• High blood pressure

• Type 2 diabetes and pre-diabetes

• Metabolic syndrome and dyslipidemia

• Obstructive sleep apnea

• Sex hormone irregularities (polycystic ovary syndrome and/or early puberty in

females; low testosterone and/or delayed puberty in males)

• Gastroesophageal reflux disease

• Gallstones

• Kidney disease and kidney stones

• Fatty liver disease and cirrhosis

• Gout

• Osteoarthritis

• Various types of cancer, including breast and colon cancer

This list emphasizes the health consequences of obesity. However, there are important

psychosocial consequences as well. There is a bidirectional relationship between obesity

and depression, meaning that those who have depression are more likely to develop

obesity, and those who have obesity are more likely to develop depression. People with

obesity may also face significant bias and stigma which contribute to adverse health

consequences. For example, greater than 70 percent of children with obesity face some

form of bullying or victimization related to their weight. People with obesity may have

a concurrent undiagnosed eating disorder, such as bulimia nervosa or night eating

syndrome. Some people with obesity may not be referred for preventive health screening

due to bias from their healthcare provider or may not pursue screening out of fear of

biased interactions with healthcare providers.

Obesity also greatly increases a person’s risk of mortality. The two leading causes of

death in the United States are heart disease and cancer, and obesity increases the risk of

both of these conditions. In fact, obesity currently ranks as number two, behind cigarette

smoking as the most common preventable cause of cancer.

When seeking treatment for obesity, many people have questions about

which approach to choose—medical management or bariatric surgery.

Before we answer that question, let’s dive into what we know about

obesity and how to effectively treat it.

Because obesity is a chronic condition, a long-term treatment approach is needed.

Lifestyle interventions such as nutrition, physical activity, and behavior modifications are

the foundation of all effective obesity treatment. Yet given the complexities of obesity and

the challenges of weight loss, other therapeutic options may need to be added. Two of

those options are anti-obesity medications and bariatric procedures.

Medical Management

Given the complexity of obesity, people should seek treatment from a clinician who is

educated on the disease of obesity and its treatment. Physicians who are board certified

by the American Board of Obesity Medicine (ABOM) and nurse practitioners and

physician assistants who hold the Certificate of Advanced Education in Obesity Medicine

from the Obesity Medicine Association have the specialized knowledge that is needed to

medically manage obesity and its complications.

Obesity Medicine specialists conduct a thorough evaluation and prescribe an

individualized treatment plan that includes a nutrition plan, a physical activity plan, and

behavior modification strategies. If appropriate, FDA approved anti-obesity medications

may be added. The patient’s response is monitored at regular intervals to determine if the

treatment is effective or needs to be modified. Long-term follow-up is often required.

Surgical Management

In addition to medical management, patients with a BMI > 40 or a BMI >35 with 2 obesity related conditions may benefit from surgical intervention. An obesity medicine clinician

will refer patients for bariatric surgery if additional treatment is advisable. Bariatric

surgery should be performed at an accredited bariatric surgery center. Accredited

bariatric surgery centers are multi-disciplinary facilities that are staffed with the following

professionals:

• Insurance coordinator

• Registered dietitian

• Psychologist

• Obesity medicine clinician—physician, nurse practitioner, or physician assistant

• Bariatric surgeon

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Because obesity is a chronic condition, long-term attention to nutrition, physical activity,

and behavioral modifications is needed, regardless of whether the person received

medical management, bariatric surgery, or both. While bariatric surgery is an effective

treatment modality, it does not replace lifestyle modifications. For all patients, including

those who have undergone bariatric surgery, anti-obesity medications may be needed to

maintain or induce further weight loss and optimize health.

Obesity is a complex chronic health condition that is treatable. A comprehensive, patient-centered approach that includes attention to nutrition, physical activity, and behavior are the foundation of treatment. However, given the chronic nature of obesity and the

challenges of adhering to an eating plan, FDA approved anti-obesity medications may also be needed to achieve the desired health results. Several anti-obesity medications have been approved by the FDA. Some are approved for short-term use, while others can be used long-term. Anti-obesity medications are most effective when they are used as part of a comprehensive treatment approach.

The decision to use anti-obesity medications is one that will be made by the patient

and their obesity medicine clinician. The choice of medication will be based on medical

history, other health conditions, current medications, and desired results. An obesity

medicine clinician will provide information on the benefits, risks, and cost of the

medications being recommended, so that the patient can determine which medication

will be the best match.

A patient’s response to a medication will be monitored at regular intervals to ensure that

the medication is achieving its desired effect. If it is not, the obesity medicine clinician

may recommend another medication in its place. Given the chronic nature of obesity,

anti-obesity medications may need to be continued long-term to keep the condition

under control. This is no different than medications used for other chronic conditions

such as diabetes, high blood pressure, and high cholesterol.

The most appropriate nutritional therapy for the treatment of obesity is one that is safe, effective, and one to which the patient will adhere. There are several nutritional plans that promote health. Due to biological diversity and individual preferences, there is no such thing as one perfect eating plan for everyone, however there are certain common trends that are found in healthy nutrition plans:

• Avoidance of processed foods

• Avoidance of added sugars

• Avoidance of trans-fats

Due to the length of time that is required to perform high-caliber studies, much of what

we know about eating and health is observational. There are several diets and eating

styles that have been maligned in the press over the years and every year new diets hit

the bookstores. Many myths about eating plans that reduce weight have been proven

wrong in recent years.

For instance, “counting calories” is often not successful over the long term because the

human body adapts to the reduced energy consumption, and over time, as appetite

increases, excess weight often comes back. By focusing only on calories, people ignore

the hormonal impact of varying macronutrient consumption (protein vs carbs vs fat).

Naturally occurring fat isn’t bad! For several decades we were under the impression that

low-fat diets were needed for health, but during that time the obesity epidemic actually

worsened. It turns out there are healthy and unhealthy fats. Man-made trans fats (found

in margarine, packaged baked goods, and used for frying fast foods) are unhealthy and

should be avoided. In comparison, monosaturated fatty acids are healthy fats that are

beneficial to both cardiac and liver health.

Most of the weight loss is indeed based on what you eat — or better yet, on what you

DON’T eat. Listed below are different types of diets/nutrition plans that have been studied

and have been proven to improve health.

Surprisingly high in fat (35-40 percent), this nutrition plan promotes monosaturated fatty

acid and omega-3 fat intake with nuts, fish, and seafood. Limited red wine is allowed.

Vegetables, fruit, legumes, whole grains, nuts and seeds are encouraged. This nutrition

plan can easily be incorporated into a low-carb or plant-based lifestyle. Benefits include a 30 percent lower risk of a first cardiovascular event, 40 percent lower risk of developing Diabetes type 2, and improvement in fatty liver disease. The Mediterranean eating style may promote only modest weight loss, likely due to the heavy incorporation of grains.

This nutrition plan focuses on how quickly and to what degree an ingested food affects

blood glucose. Popularized with the South Beach Diet, a 2010 study in the New England

Journal of Medicine found this eating style to be beneficial for weight maintenance after

patients lost more than 8 percent of their total body weight.

Low-carb eating styles

Popularized by Atkins, keto, and often incorporated into Paleo eating styles. Carbohydrate

amounts are controlled. This is a good eating style for those with diabetes since it reduces

insulin secretion and improves blood sugar levels. Low-carb eating can be incorporated

into any nutritional lifestyle and often promotes the most weight loss, lowers triglycerides,

and may increase HDL or “good” cholesterol.

These nutrition plans consist of foods that come primarily or exclusively from plants and

avoid animal protein. There are many variants, some of which are like traditional

Mediterranean eating styles. Vegans eat only plant-based foods, but other variants allow

occasional fish (pescatarian), dairy products and eggs (lacto-ovo vegetarian), or even

meat and animal products in moderation (flexitarian).

There are several commercial programs that address behavior and accountability to help

promote the type of lifestyle changes that are needed to both lose and maintain the loss

of excess weight. These programs may incorporate group meetings and one-on-one

counseling and are therefore not pure diets/nutrition plans as much as they are “lifestyle

programs.” The most successful of these programs — just like the most successful

nutrition plans — still borrow from the same basic tenets:

• Avoid or limit processed foods (man-made foods, baked goods, sweets, batter-fried

foods)

• Avoid added sugars (table sugar, high-fructose corn syrup, honey, etc.)

• Avoid trans-fats