Obesity

We are starting a feature series that will highlight news that can truly EmPower you to a healthier life. Science is moving ahead at an incredible pace--the challenge is keeping up without feeling overwhelmed and being able to look at what can be personally helpful. So what has hit the presses recently?

“Active Lifestyle Appears as Beneficial as Structured Exercise”

(American Journal of Health Promotion, 2013;27:143-51)

Exercise, exercise, exercise! We have all heard this advice, that physical activity keeps us healthy, helps manage chronic conditions such as diabetes, helps prevent heart disease. But just what type of exercise is the best, or how much should one do, for how long? Surprisingly, scientific data to answer these questions is sparse! A recent study by Loprinzi and Cardinal suggests that short and small amounts of physical activity that add up to 30 minutes per day may be just as beneficial as a more defined or structured physical workout. Using data from the NHANES (National Health and Nutrition Examination Survey) 2003-2006, the researchers looked at results including 6,321 people, ages 18-65 years. The researchers defined a “bout” as 10 minutes of activity or more and a “non-bout” as less than 10 minutes of activity. “Non-bout” included activities such as walking or pacing while speaking on the phone, or taking the stairs rather than the elevator. Analysis of results based on NHANES data and a questionnaire on current health status showed that an accumulation of “non-bout” short bursts of physical activity totaling 30 minutes daily can be as beneficial as “bouts” or structured activity, with respect to health.

So what can you do to get those 30 minutes accumulated?

• Take the stairs, skip the elevator
• Dance while you talk on the phone
• Stand and march in place while you check e-mails
• Get up at each commercial break while watching TV, then bend over and try to touch your toes, stand and repeat, until the commercial break finishes
• Pack your groceries to just half full in bags, then just take in two bags at a time,

It all adds up!

“Myths, Presumptions, and Facts About Obesity”

(New England Journal of Medicine 2013;368:446-54)

Myths are what we believe and have no facts to support the beliefs. Presumptions are what we assume, with no facts to support. And facts, well, facts--at least in science--have some backing. This article on myths, presumptions and facts about obesity focused on whether we really know what we think we know.

The seven myths reviewed included that small but persistent lifestyle changes will, over time, result in large, long-term weight loss; that setting small goals for weight loss is more successful than setting large goals; that rapid, large weight loss is more likely to be associated with weight being regained; that a sense of feeling ready to lose weight is associated with better success at weight loss; that participation in physical education as is currently available in schools will prevent weight gain in childhood; that breast feeding prevents obesity; and that sexual activity can burn a significant amount of calories.

Surprised? The authors note that with weight loss, the energy requirements of the body change, so continued lifestyle changes are required to adapt to the changing energy requirements with weight loss. In setting goals of weight loss, actually there are studies that suggest that more ambitious weight loss goals may actually be linked to better success at weight loss! Looking at comparisons of rates of weight loss, there have been no differences noted with regard to keeping weight off, whether the loss has been fast or slow. Diet readiness might seem like a “no brainer”- losing weight should be more likely to occur if we feel ready to lose weight, but this does not seem to make a difference. The authors state that the explanation might just be that people who start a weight loss program are, by definition, ready. Physical education classes do not prevent childhood obesity, at least as currently provided in schools. Breast feeding does not act as a prevention of childhood obesity. And finally, sexual activity, although calorie burning, is not a significant calorie-burning activity. The example given is that a 154-pound man might burn the same amount of calories per minute in sexual activity as he would walking a moderate pace-2.5 miles per hour. Left to the reader is preference of activity!

Presumptions noted in the article include that eating breakfast is protective against obesity-not supported by the two studies reviewed, which showed no effect, whether breakfast is eaten or not. However, one of these studies might have been biased by assigning people to either the breakfast eaters or non-eaters group by whether they already ate or did not eat breakfast-not a true random set-up that, by definition, is needed for a study to be considered a good study. Additionally, there is no data to support that what we learn in early childhood as to habits of exercise and eating cannot be changed as we age. And while fruits and vegetables are recognized as being part of a healthy diet, they do not by themselves protect against weight gain. We have all heard about “yo-yo” dieting, but it is not at all clear that this is bad. Although there are reports linking this weight variation with higher risk of death, it has been difficult to separate the
dieting from other health conditions present. So, is it the diet or illness?

And surprisingly, no study has clearly shown that snacking is an automatic way to gain weight. Finally, does having ready access to parks in the neighborhood guarantee less obesity? Certainly not, if they are there but not used!

Discouraged? Do not know what to believe or not believe? Has science failed us in providing any solid information about weight management and, more specifically, about weight loss? The authors do come through with helpful information!

The authors review studies that suggest changing one’s lifestyle can make a big difference and weight loss can be achieved-we are not prisoners of our genetic makeup. Reducing food intake and increasing physical activity works! Physical activity in particular is needed, and to lose weight, a substantial amount of it, beyond just that for good health maintenance. Obesity needs to be accepted as a chronic condition needing ongoing attention, just as does having a chronic condition such as high blood pressure or diabetes. For children who are overweight, not just school or out-of-home places need to be supportive of and emphasize how to develop a healthier lifestyle, but support in the home and active involvement in the home is critical to success in weight loss and weight management. Finally, pre-prepared meals, meal replacements, weight loss drugs and weight loss surgery are options that can and do work in helping to lose and maintain weight loss. They are not for everyone. There are costs and potential side effects to consider.

So what should you take away from this article, if you want to lose weight?

• Be aware of how many calories you eat (and eat less if you want to lose weight)
• Increase physical activity to use up those calories (and be even more active, if you want to lose weight)
• Be aware that achieving and then maintaining weight loss will be an ongoing challenge (but one that you can win!)

Body Composition, Fat Distribution and Obesity: Impact in South Asians

By Annaswamy Raji, MD

Obesity is a growing problem all around the world. It is associated with many metabolic complications, including diabetes and heart disease. On a very simple level, body weight depends on the balance between number of calories consumed, stored and burned. Each of these is influenced by the person’s combination of genes, environment and behavioral components.

Health care providers all around the world use body mass index (BMI), which is an approximate measure of body fat in a person based on their height and weight.

According to World Health Organization, India will have the highest number of people with type 2 diabetes by the year 2025 AD (57 million), followed by China (38 million) and the USA (22 million). The greatest increase (195%) in the number of people with type 2 diabetes between 1995 and 2025 is expected to occur in India. Researchers have shown higher rates of diabetes and heart disease in Asian Indians migrated from rural to urban India, and to developed countries like the USA and United Kingdom. We don’t have many studies that look at risk factors in rural and urban Asian Indians, or migrant Asian Indians in the USA A recent study found that a high number of Asian Indians in the USA have diabetes, prediabetes, and the metabolic syndrome.

South Asian Americans are the fastest growing immigrant group in the United States. Overweight (adults: 38% - 57%, children: 18% - 43%) and obesity (24%) rates in Asian Americans, especially South Asian Americans, are increasing.
Our group and others have compared Caucasians (non South Asians) to South Asians. South Asians have more fat around the middle and many risk markers for heart disease and diabetes. Body composition and where the fat lies play important roles in causing diabetes and heart disease. These important issues need to be considered in patients of South Asian ancestry. All these studies tell us that looking at BMI alone in South Asians may not be enough to assess the risk factors for diabetes and heart disease. It appears that the BMI cutoffs for obesity are different from that of Caucasians. Researchers are looking to define obesity cut points (BMI and waist circumference) in multiethnic populations to better assess and treat metabolic complications in non-European populations. For now the World Health Organization (WHO) suggests that obesity be diagnosed at a BMI of 27 in an Asian population.

The South Asian population in the USA is relatively young and very diverse. Therefore there is a need for early and culturally appropriate intervention. Education and lifestyle changes (nutrition and physical activity) are needed to prevent metabolic complications.

http://www.ndep.nih.gov

The bottom line is this. If you are Asian-American, you are at risk for metabolic complications at a lower BMI than a person of European ancestry. Get in to see your doctor at least on a yearly basis to document that you don’t have diabetes, high blood pressure, high cholesterol, or other risk factors for premature heart disease. And follow the suggestions in this issue of Power of Prevention® Magazine to keep your weight down.

Annaswamy Raji, MD, M.M.Sc, is the Director of Diabetes and Metabolism at Parkland Medical Center in Derry, NH, and Assistant Professor at Harvard Medical School, Boston, MA. She is Board certified in both internal medicine and endocrinology. She obtained her fellowship in endocrinology at the Brigham & Women’s Hospital Boston, MA, and Masters in Medical Science from Harvard Medical School. Dr. Raji is a trained clinical endocrinologist and a clinical investigator with primary interest in clinical research in the areas of insulin resistance, diabetes and obesity and was the Director for program for weight management at the Brigham & Women’s Hospital until April 2009.

Schools Can Help with Childhood Obesity

By Becky González-Campoy

The message is simple. Eat more fruits and vegetables. Control portion size. Move your body regularly and often. Follow these steps and you reduce the risk of obesity and its complications. So why are today’s children more likely to die at a younger age than their parents? They haven’t been getting the message. Not at home. Not at school. Not in the media.

In theory, the solution is also simple. Teach children and their families about how to live healthy lifestyles and motivate them to apply what they learn. The key is to involve kids in the process both at home and at school. Here’s how.

Start by modeling healthy behavior yourself. Take kids shopping for groceries. Have them select food for your family. Teach them how to read nutrition labels. Introduce them to many tastes and textures. Make time to be physically active together. Encourage your kids to choose activities they can do all of their lives.

Get involved with promoting healthy living at your child’s school. The Child Nutrition and WIC [Women, Infants, and Children] Reauthorization Act of 2004 requires all school districts that receive federal funding from the school lunch program to have a wellness policy in place. The purpose of this policy is to ensure that school environments promote and protect students’ health, well-being, and ability to learn by supporting healthy eating and physical activity. It’s also designed to promote employee wellness to improve productivity and reduce rising healthcare costs.

I am a parent of three children ages 22, 19, and 16. I am also a former school board member from a suburban district in Minnesota. I am currently helping this school district to get its Wellness Policy up and running. Most schools should have a Wellness Advisory Committee that oversees activities to promote and sustain wellness for students and staff. This group provides a valuable opportunity for collaboration among parents, teachers, administrators, community members and students to develop effective methods for promoting wellness.

Before our Wellness Committee could plan its strategy for improving health, each school had to determine its strengths and weaknesses. We used an online assessment tool called the Healthy School Builder (see box) to collect baseline data about our school’s breakfast/lunch programs, health and physical education curriculum, and current wellness practices, among other things. This information helped each school create an individualized plan to meet the gold standard set forth by the Healthy School Builder.

Ongoing communication is an essential part of any strategic plan to bring about change. Knowing we have several audiences we must educate and motivate, we use several avenues to deliver wellness information and resources:

• Posters and parent newsletters. The district’s wellness liaison collects and distributes posters and healthy living tips via e-mail to key staff at each school. Fruits and vegetables might be featured one month; how to beat stress might be featured another month. Teachers can display the posters in classrooms or common areas. Principals can include the healthy living tips in their newsletters to families.
• District Web site. The district Web site provides a wellness home page with links to each school’s wellness page. We created a name for this link that started with a letter near the beginning of the alphabet so visitors would be sure to see it – Center for Wellness. Here parents and staff can learn about the latest wellness activities at each school and find resources to help them lead healthier lifestyles.
• School-wide announcements. Principals and students deliver healthy living tips during daily announcements.

Among the most valuable contributions Wellness Advisory Committee members provide is feedback regarding how effective the current activities are and how we can improve the program. I pushed hard to include secondary students on our committee for two reasons: First, almost no resources for reaching secondary students exist – most youth wellness programs are geared toward children in pre-school through 6th grade. Second, students know best how to reach their peers.

The students on our Wellness Committee provide the adult members with a reality check. School announcements at the high school? No one listens to them. Abundant healthy options at lunch? Not so much. We need vegetarian options. We need intra-mural sports opportunities. Reach us through media we actually use. Their input prompted a student survey of lunch menu options and suggestions for improvement. Student feedback also led us to consider other venues to deliver the healthy lifestyle message. Students spend time on Facebook, not the district Web site. They use text messages regularly. We’re now exploring the use of Twitter to send quick healthy living messages to students and others who spend time on their cell phones or on the Internet.

We’re also learning the value of working with other schools and health agencies. Five districts in northern Dakota County, Minnesota, are working together with the Dakota County Public Health Department on a 5-year grant to promote eating more fruits and vegetables at school and at home. Through this alliance, we connected with Catalyst, a group that helps students lead the way to improving health among their peers.

We invited Catalyst members to work with students at our high school, to help us prepare our strategic plan to boost the consumption of fruits and vegetables. The group is working on a student-oriented video that schools can run on monitors mounted in their hallways and cafeterias. The students will develop a healthy living mentoring program for elementary students as well.

We’ve replaced soda with water in the vending machines. No more super-sized bottles of Mountain Dew. Our lunches include more salads, fruits, baked foods instead of fried foods, and smaller portions. No more sugary drinks and donuts to start the day for students.

Our toughest sell? Getting the adults to improve their nutrition and increase their physical activity. Again, feedback from Wellness Committee members proved to be very valuable. Principals serving on the Committee pointed out that teachers are more likely to listen to their peers rather than to district administrators. So our approach is similar with staff as it is with students – encourage teachers with a passion for healthy living to inspire others through example. We encourage anyone with a great idea to run with it. As a result, we are seeing the start-up of special interest groups, such as walking clubs and yoga classes.

Incorporating health promotion in schools requires teachers to understand its importance. Teachers are often overloaded with other demands. Here, we focus on research that links good health to solid student performance. Healthy kids are better able to learn than those who are poorly nourished and sedentary.

Our efforts to promote wellness extend to school fundraisers and concessions at athletic events. We are slowly replacing candy sales with wrapping paper, plants, school spirit wear, and other options. The challenge is to convince those whose programs depend on these sales that these alternatives make as much money. Granola bars, fruit, and water are making their way onto the menus of the concession stands.

Call your school to find out what your district is doing to promote healthy living and ask how you can join the effort. It’s that simple.

Becky González-Campoy is Chief Operating Officer of the Minnesota Center for Obesity, Metabolism and Endocrinology (MNCOME), PA and Executive Director of MNCOME Foundation. Becky holds a Bachelor of Arts degree from Macalester College (1983), St. Paul. She’s a Past President of the Minnesota Medical Association Alliance and is a former member of the Board of Education for Independent School District 197 (West St. Paul/Mendota Heights). She currently is working with the school district to implement its Wellness Policy.

By Bryan Campbell

I came up with a response to Julie’s question, but it requires a bit of introspection on my part. You see, I used to weigh 308 pounds.

I remember the day I got on the scale and saw that number. I have never been “skinny.” Ever since elementary school I was picked on as the “fat” kid. In high school, I was not obese, but I was certainly heavier than most of my friends. Much like Julie, I tried to make up for my physical problems with humor. I often made fun of myself.

But the climb from the high school 190 pounds (it sounds so glorious today, I can’t believe the lack of perspective I had!), to 308 pounds was a slow and steady one. I didn’t reach my full adult height of 6’3” until I was almost 21 years old. And from that point on, I gained a few pounds every year until that epiphany moment, 308.

My life changed when I was lucky enough to be working on a project with Bob Harper, trainer from The Biggest Loser. I asked him for advice and he told me, “If you really want my help, then I’m going to tell you what to do and what not to do as long as I am with you. If you won’t listen to me, then we’re done. If you ask me again to help you, I will.”

Bob wanted me to know what I was getting into before he agreed to help. That’s why he gave me that one last chance to back away. If I asked again, he knew I was committed to changing my life.

And so I did. I never worked out with Bob, but I ate with him. He showed me in three or four meals the principles I would need to eat healthy for the rest of my life. He told me that I need to get in a minimum of 30 minutes of movement every day. After five days with Bob, I had lost 11 pounds!

Bob also shared with me a piece of advice that has kept his nutrition training in my head. He told me that it’s never too late to start, and that if you really want to make a change, start now. He told me that when people say that they are going to start on Monday morning, or that they are going to make a New Year’s Resolution, they are already making excuses.

I started eating better and going to the gym for 30 minutes during my lunch hour. After a while, my entire family was eating healthier. Now, my wife and I get up in the morning and spend an hour in the gym before work. It’s been a great bonding experience for us, and has helped to motivate me on days when I just don’t want to get out of bed.

Today I am 231 pounds. Not perfect, but at least it’s moving in the right direction. I am now running 3 days a week, and ran my first half-marathon on Thanksgiving Day, 2009. My current goal is to finish the National 15k Championship in under an hour and 30 minutes. You can monitor my training and see if I do it on my blog (http://bryansrunningjournal.wordpress.com). I’d love to hear about your progress too.

But if this is indeed the last time I have the chance to speak through words to you, I guess my answer to Julie’s question is fairly simple.

Start now.

Think about the next meal you are going to eat? What’s one thing you can do to make it healthier? How will you work 30 minutes of movement into your day?

Then, use the resources you have available to you. This magazine is a good start. You can find good nutritional and physical activity information in these pages. Talk to your friends. Let them know what you are about to start. I promise you, they would love to provide positive support for your efforts.

But most importantly, start now!

You will have moments of weakness. I can’t resist pizza (neither can Julie, see the online exclusive) and there are times when I break down and have three or four pieces. But once it’s over, I understand the amount of work it will take to make up for that pizza, and I commit to start my program again.

I hope that you are inspired by Julie, and that I have helped provide you some of the tools needed to make a change for the rest of your life. Now it’s up to you.

Learning to Live: A Patient Story

By Sarah Senn

Everyone needs to eat to live, but what happens when you live to eat? Yehuda Greenwald, a husband, father of four and industrial equipment salesman from New York, struggled with this question all of his life.

After years of dieting and countless hours spent working out, Yehuda continued to experience the literal ups and downs of weight loss. Despite his efforts, he kept gaining weight and his medical complications worsened. After exhausting all other treatment options, Yehuda’s endocrinologist decided that it was in his best interest to pursue a more drastic measure – bariatric surgery.

Before his surgery, Yehuda actively worked with his endocrinologist and a nutritionist to manage his condition through balanced nutrition and physical activity. For nearly 5 years, Yehuda took medication to help suppress his appetite. While he was able to lose more than 35 lbs with this treatment, after he stopped taking the medication, his weight started to rise again. Even after restricting his calorie intake and exercising at least three to four times per week, Yehuda still gained at least 2 lbs per month.

“Everyday I would come home from work, and have to lie down immediately because of pure exhaustion,” he remembers. “I felt so drained.”

Yehuda visited his endocrinologist for a routine check-up and blood tests. Those tests revealed that he had type 2 diabetes. In just months, Yehuda had gained 30 lbs and was taking high doses of insulin along with 14 other daily medications. Unfortunately, his diabetes was spiraling out of control. It was at this point that Yehuda realized how much his quality of life was diminishing because of his weight.

“As I was getting older, given the way things were going, it was only a matter of time before I had other complications,” he says.

On January 6, 2009, Yehuda underwent surgery to put in a LAP-BAND®, which limits the amount of food that can enter the stomach. As with most bariatric surgery patients, Yehuda spent many hours in counseling with a dietitian learning to understand the physical effects of the surgery on his body. He had to adopt new eating habits and learn when he was full. In just a few short weeks, Yehuda began to see the results of the surgery and his health improved.

Before the surgery, Yehuda weighed 287 lbs. As of November 2009, he had lost 78 lbs. Now at 209 lbs., Yehuda is not only looking different, but he feels different too. As Yehuda continues to lose weight, he recognizes it’s still a work in progress. Yehuda recently went to a buffet and loaded his plate full of food out of habit only to realize that he wouldn’t be able to eat it all.

“It’s okay to walk away with food on the plate,” he admits.

Since the surgery, Yehuda has more energy and enjoys spending time with his family. He no longer snores and is able to be more active with his children. However, the most profound change that Yehuda has experienced apart from the physical weight loss is that his diabetes is under control and he only takes a few medications each day.

“I’m a regular person again,” Yehuda boasts. “The way I look at food now is that I eat food to live instead of living to eat food.

Is Bariatric or Metabolic Surgery Right for Me?
By Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU

In the ever-frustrating “Battle of the Bulge,” it is best to PREVENT weight gain. Prevention takes the form of healthy eating and physical activity. Unfortunately, many of us fall behind the curve, and over time the pounds pile on. Based on our own personal lifestyle, genetics and medical care, we become “overweight,” or even “obese” (see www.EmPowerYourHealth.org/obesity for more information).

If we do become obese, what are the proven treatments that our doctors can recommend? First and foremost is still a change in lifestyle. All of us can become more physically active. And all of us can control our food portions. If that doesn’t work, then there are certain medicines that help with weight loss. Medications and lifestyle changes are discussed by other authors in this issue. But sometimes lifestyle changes and medications together don’t help you lose weight. If the obesity is severe enough, then there may be a role for surgery of the digestive tract to help with weight loss.

The term “bariatric” [bah-ree-AH-trick] refers to the field of medicine concerned with weight loss. “Bariatric surgery” refers to surgery for weight loss in a person who is obese. Many of us know about complications from bariatric surgery. These complications were mostly from surgeries done in the 1950s through 1970s. During that time, many patients had life-threatening nutritional deficiencies. Fortunately, the currently approved bariatric procedures are considered to be safe and effective. Deciding to have one of these procedures requires help from an expert. This is because each bariatric surgery has its own risks and benefits. Each decision to have bariatric surgery needs to be an individual decision.
Bariatric procedures are right for persons with a body mass index (BMI) of >40 (extreme obesity) or a BMI >35 if there are obesity-related complications such as diabetes, hypertension, high cholesterol, or sleep apnea (halted breathing while you sleep). To calculate your BMI, visit www.powerofprevention.com/bmi/php.

A complete medical evaluation, including a nutritional evaluation, is needed before the surgery. Depending on one’s particular insurance policy, candidates may need to fulfill certain requirements before having surgery. These requirements should be explained by the bariatric surgeon at the time of the initial appointment. The two most common procedures are the laparoscopic [lah-pa-row-SKAH-pic] adjustable gastric band (or “band”) and the Roux [roo]-en-Y gastric bypass (or “bypass”).

BAND PROCEDURE

In the band procedure a plastic ring-like device is placed around the top part of the stomach near the entry of the food-pipe (esophagus). It is done with laparoscopy [lah-pa-RAH-skah-pee], using instruments inserted through several small incisions in the belly. Scarring is minimal. The effect of this procedure is to limit the amount of food entering the stomach. People who have this procedure can’t overeat, so they lose weight. The band can be tightened or loosened at any time after the surgery. This way, weight loss can be controlled: not too slow, not too fast. This procedure is associated with acceptable amounts of weight loss (14 – 60% excess weight loss after 7 – 10 years from surgery). There is very little risk for nutritional deficiencies or surgical complications. Nevertheless, one in every three people who had the band procedure develops iron deficiency and need to take iron supplements. The band procedure is gaining popularity around the world.

ROUX-EN-Y BYPASS PROCEDURE

The bypass procedure is a more involved surgery. It is usually done by laparoscopy. In this procedure, food enters a smaller stomach that is created surgically. This limits food intake, like the banding procedure. The first half of the small intestine is also bypassed. This is how the Roux-en-Y procedure also gets the name “bypass.” Digestion normally occurs in the first part of the small intestine. In the bypass, the exit to the stomach is cut and reattached to a more distant part of the small intestine. Full digestion doesn’t occur. This means there is less absorption of food, or “malabsorption.” Since this is a more involved surgery which causes malabsorption, the risks are higher. However, the malabsorption part causes more excess weight loss by 7 – 10 years (up to 70%). People who have the bypass procedure need to be monitored regularly for vitamin and mineral deficiencies and take dietary supplements as directed by their doctor.

OTHER BARIATRIC SURGERIES

There are other bariatric surgeries that deserve mention:

• The sleeve gastrectomy (or “sleeve”) is a relatively new procedure, not generally paid for by medical insurance. The sleeve procedure involves the creation of a smaller stomach but without causing malabsorption.
• The biliopancreatic [bill-ee-oh-pan-kree-AT-ic] diversion with duodenal [dew-oh-DEE-null] switch (or “switch”) is a procedure that is associated with greater amounts of weight loss. This weight loss comes with a price: more nutritional deficiencies. Sometimes “the switch” needs to be reversed because the patient loses too much protein. This procedure is much less common.

PUTTING IT ALL TOGETHER

Overall, bariatric surgery is an appropriate treatment for severe obesity in patients who are at high risk for obesity-related complications, such as heart attacks and strokes. Bariatric surgery should only be considered in patients who did not have success with lifestyle changes, medical nutrition therapy, and treatment with medications.

The band and bypass procedures are safe and effective. These two procedures prolong life when performed in appropriate candidates. The weight loss that comes from bariatric surgery reverses many of the complications of obesity. Type 2 diabetes typically gets much better or even disappears after the surgery.

Bariatric surgery requires a personal commitment to a lifetime of healthy eating and physical activity. Bariatric surgery also requires long-term medical follow-up to monitor for complications. And for people who have malabsorptive procedures, there is a need for lifelong vitamin and mineral supplementation. A team approach to obesity, including dieticians and counselors, is required before and after bariatric surgery.

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU, received his M.D. degree from Mount Sinai School of Medicine in 1985. He then completed his residency in Internal Medicine at the Baylor College of Medicine in 1988. After returning to Mount Sinai to complete his fellowship training in Endocrinology, Metabolism and Nutrition in 1990, Dr. Mechanick started his private practice in Manhattan in Endocrinology, Diabetes and Metabolic Support. Since then, he has become the Director of Metabolic Support and Clinical Professor of Medicine in the Division of Endocrinology, Diabetes and Bone Disease at the Mount Sinai Hospital. He continues to care for many patients with endocrine, diabetes and nutritional disorders, as well as train physicians in endocrinology and nutrition.

Weight Loss Medications

By David A. Westbrock, MD, FACP, FACE

IF AT FIRST YOU DON’T SUCCEED…
Obesity is a biological and treatable disease. The question everyone should ask is “what is the risk to my health from not treating obesity?” And then one should ask, “what is the benefit and risk of using medications to treat obesity?” To understand the use of medications to treat obesity, let’s review their history.

The use of drugs for weight loss is as old as medical practice. From as long ago as 2000 BC, Indian remedies known as ayurvedic [eye-yer-VAY-dik] herbs were used for weight loss. These herbs included cayenne pepper, licorice root and cinnamon.

In the US, medications have been used to help people lose weight. Unfortunately, several obstacles have confronted those who used these drugs in the past. Thyroid extract was introduced in the late 1800s. To achieve effective weight loss it had to cause hyperthyroidism. In the 1930s, dinitrophenol [die-nigh-troh-FEE-null], a then popular drug, was one of the first drugs that carried FDA warnings and became restricted. Dinitrophenol use was associated with cataracts, blood disorders and death. Later, rainbow pills, a mixture of many unrelated drugs, such as digitalis, thyroid, and diuretics were found to cause multiple deaths. Then amphetamines [am-FET-ah-meens] were widely available until the late 1970s. Amphetamines are now restricted because they are addicting and may cause side effects on the heart and nervous system.

In the 1990s the drugs fenfluramine [fen-FLOO-ra-meen] (previously marketed as Pondimin) and dexfenfluramine [dex-fen-FLOO-ra-meen] (Redux) were used to treat obesity. Fenfluramine was used in combination with phentermine [fen-ter-meen] (Fen-Phen). Fenfluramine and dexfenfluramine were taken off the market after reports of heart valve problems in association with their use.

A popular decongestant medication used for appetite suppression, Dexatrim, was also withdrawn by the FDA. Dexatrim was associated with an increased risk of stroke in 1 in 100,000 women who took the drug for the first time.

With this history, it is not surprising that many doctors shy away from using any obesity medications.

WHERE ARE WE NOW?

In the 1960s and 1970s benzphetamine [benz-FEHT-ah-meen], phendimetrazine [fen-dih-MET-rah-zeen], diethylpropion [die-ethyl-PRO-pree-on] and phentermine (marketed as Tenuate and Adipex) were introduced into the market. For all of these medications, weight loss is approximately 2-3 times as much as weight loss with a placebo drug (sugar pill). These medications are still available today. At the time of their approval, the recent experience with amphetamines led the Food and Drug Administration (FDA) to limit these medications for short-term use (up to 12 weeks). The concern at the time was that these medications could be addictive, like the amphetamines. This was an understandable concern at the time. Additionally, obesity was not considered a disease back then, like it is now.

We now understand that treating obesity and overweight require a long-term commitment. For this reason, intermittent use of these medications may be considered. Intermittent use has been shown to give similar results to continuous use for phentermine. In my experience, weight regain is common after stopping the medications if the patient is not closely supervised.

There are only two FDA-approved obesity drugs for extended use.

Orlistat is available over the counter as Alli, or by prescription as Xenical [ZEN-ih-kal]. It works by blocking the absorption of dietary fat. It is less effective in people who eat a low-fat diet. When fat is not absorbed by the gut it will go right through. Possible side effects of orlistat include oily stools, loose stools, frequent stools, and stool accidents. These side effects are easily avoidable by eating less fat and using soluble [SAHL-you-bull] fiber. Soluble fiber holds the oily residue in the gut making it less irritating. To prevent fat-soluble vitamin malabsorption, a multivitamin should be taken every night, away from meals.

Sibutramine [sigh-BYOO-trah-meen], available as Meridia, works on the brain to cause early fullness. Sibutramine may raise metabolism. It is not habit forming. Sibutramine increases serotonin [seh-roh-TONE-in] levels in the brain and needs to be used with caution in patients also using antidepressants known as SSRIs (selective serotonin reuptake inhibitors). These include, for example, Prozac, Zoloft, Celexa and others. Using sibutramine and these antidepressants together may overstimulate the central nervous system.

In November 2009, the FDA issued a warning about sibutramine. Preliminary data from the SCOUT trial suggests that patients using sibutramine have a higher number of cardiovascular events (heart attack, stroke, resuscitated cardiac arrest, or death) than patients using a placebo (sugar pill). Although this is a preliminary review of the data, sibutramine and other medications that act on the brain have to be used with caution. Talk to your doctor about the benefit and risk of these medications. Clearly, the blood pressure and cholesterol have to be treated independently of the weight.

Orlistat and sibutramine cause a loss of 5-10% of body weight. Most weight is lost within the first 6 months. When continued beyond the initial weight-loss phase, orlistat and sibutramine help prevent weight regain.

There are, of course, many products touted as natural remedies for weight reduction. Two are recently the most popular, and they include acai, a fruit of Brazilian origin and hoodia, a product of the Kalahari Desert in Africa. Acai has anti-oxidant properties and is being studied for preventing hardening of the arteries and as an anti-cancer agent, but it has no proven benefit as a weight loss drug. Hoodia is touted in advertisements as a natural product that, as used by African bushmen, can suppress appetite. While this claim is true, no evidence is yet available (although it is being researched) to support claims that commercially available products of hoodia are either safe or effective. As health care consumers resort to natural products from health food stores and Internet outlets, it is very important that the use of any of these products be considered only after consulting a doctor.

Metformin is now the most commonly prescribed drug as initial therapy for type 2 diabetes. It had been, until recently, the only drug for diabetes that has aided in weight loss. Exenatide and pramlintide are injectable medications recently approved for the treatment of diabetes. Both have been shown to improve blood sugars after meals as well as fasting. Both drugs slow stomach emptying, and though nausea is the most common side effect, the drugs have been shown to cause weight loss. Although these anti-diabetic medications are not FDA approved for weight loss, they have this added benefit. In addition, metformin has been shown to prevent diabetes.

Topiramate, zoniamide and lamotrigene are anti-seizure drugs that generally result in weight reduction. They are used “off-label” to help with weight management, because they are not currently approved by the FDA for weight loss.
Several medications may result in weight gain. These include many of the most widely used medications to improve mental health. Ask your doctor about the weight effects of medications that you are being prescribed.

THE FUTURE – THEN TRY, TRY AGAIN…

The future of obesity medications is very positive. It is recognized that obesity is not only a serious health problem for the individual patient, and new drugs to help are constantly being studied. This includes several other medications that track the chemical messages between fat cells, the stomach and intestines, and the brain.

Obesity medications should always be used in addition to ongoing lifestyle changes, with improved nutrition and increased physical activity. And remember that cardiovascular risk factors such as high blood pressure and high cholesterol have to be aggressively treated independent of the weight.

David A. Westbrock, MD, FACP, FACE, has been in private practice for nearly 30 years in Dayton, Ohio. He is certified by the American Board of Internal Medicine in Internal Medicine and Endocrinology/Metabolism. He received his undergraduate degree from the University of Dayton and his medical degree from the Ohio State University. Dr. Westbrock is an associate clinical professor of medicine at Wright State University. Dr. Westbrock is one of the Dayton area’s premier obesity experts. He created New Profile Weight Management Center in 1998. In it, he aims to create a permanent solution for patients’ health as it relates to weight management as well as a model for preventative health care in other chronic disease states. A Dayton area resident for the vast majority of his life, Dr. Westbrock has been married for 35 years and has three children.

Newfound Simplicity: A Patient Story

By Sarah Senn

A self-proclaimed “all-or-nothing dieter,” Kathy Gallagher has struggled with her weight from an early age. Home-cooked, family-style meals did not afford her any breaks as a child. Kathy continued to struggle with her weight through high school and up until she got married. At her peak, Kathy weighed 290 lbs.

Kathy, who has worked for the City of St. Paul, Minnesota, for over 30 years, has tried every diet in the book, including one that restricts you to one hamburger and one candy bar a day. The success of those diets was short-lived and the results never lasted longer than a few months.

“I told myself, ‘If I keep doing what I’m doing, it’s never going to change,’” she remembers.

After reading countless articles about the serious complications of obesity, Kathy became even more motivated to lose weight when one of her friends had gastric bypass surgery. Determined not to be left behind, she started with baby steps by eating less and moving more. In just a few weeks, Kathy began to shed the pounds.

Realizing the difficulty of losing weight by herself, Kathy formed a support group with a couple of her friends where they could meet weekly to share the burden and encourage each other. Together, the group confronted the challenges of losing and maintaining weight and proved the value of strength in numbers. Kathy acknowledges that while her friends were essential to her success, she could not have accomplished her goals without the support of her husband and family as well.

Now at age 53, Kathy weighs 165 lbs and is healthier than she’s ever been. She maintains her weight by eating well-balanced meals and staying active. Kathy’s recent weight loss has inspired other members of her family to do the same. Her two brothers, sister-in-law and niece have lost more than 300 lbs combined.

While she admits that she still wrestles with food choices and daily workouts, Kathy has a positive outlook on life. Her self-esteem is higher and she doesn’t worry as much about weight-related health complications.

For Kathy, the simple changes have been just as rewarding – things such as finding clothes that fit great – no more plus sizes! – and fitting into an airplane seat with room to spare have made life more enjoyable. “I marvel at the little things,” she reflects. Looking back on how far she has come in just a couple of years, Kathy can’t help but be amazed at the difference the weight loss has made in all aspects of her life.

“It is so worth it. It’s difficult, but the rewards are astronomical,” Kathy says. “It can be done,” she continues. “You just have to believe in yourself and never let the little missteps along the way derail you.” And on those days when she most struggles, Kathy reminds herself: “It’s hard to follow a meal plan, and it’s hard to maintain your weight. But living is harder when you’re obese.”

What are the Complications of Obesity?

By Dace L. Trence, MD, FACE

Who would not like to look thin? Going to a wedding or reunion? Want to get into those jeans that fit so well just a few years ago? We cannot escape the changes that happen to our body over the years. But being overweight has consequences beyond how we look or how we might not fit into old clothes. Obesity is a disease because it can shorten your life and because it causes complications. Obesity causes problems with your body, your metabolism, and your mental health. Let’s discuss some of the problems caused by obesity.
People with higher weights have shorter lifespans. If a person is obese at the age of 40, life will be shortened by 7 years. This shorter life expectancy is from weight-associated effects alone. Obesity also causes many life-shortening conditions:

• Ninety percent of people who develop type 2 diabetes will have a body mass index (BMI) greater than 23.
• The risk of getting type 2 diabetes is highest if the weight is gained during childhood and there is a family history of diabetes, abdominal obesity, or mother having had gestational diabetes.
• If you have obesity, the chance of developing high blood pressure is up to five times greater compared to someone with a normal weight.
• Eighty-five percent of those diagnosed with high blood pressure have a BMI above 25.
• Increasing cholesterol levels are associated with weight increases above a BMI of as little as 21.

High cholesterol, elevated blood pressure and the presence of diabetes in turn lead to increased heart disease.

• In a study with over 300,000 people followed-up over 7 years, every unit increase in BMI led to a 9% increased risk for heart attack.
• In the same study there was an 8% increased risk of stroke.
• In women with obesity plus high blood pressure, 70% will develop an enlarged heart and 14% will get heart failure.

Breathing capacity can be affected by having obesity.

• Sleep apnea (halted breathing during sleep) is much more common in those who have obesity.
• Asthma is more common as BMI goes up.
• Collapse of lung tissues and more lung infections are more common after anesthesia for surgery in patients with obesity.

In joints that carry excessive weight, such as the hips and knees, arthritis tends to be a problem. There is also evidence that other joints, like the ones in the hands, might also be more involved. And gout is also more common.
Not as well known is that many cancers are more common in patients with obesity.

• The World Health Organization International Agency for Research into Cancer has estimated that being overweight (and also sedentary) might account for up to 25-30% of cancers of the breast, colon, uterus, kidney and esophagus.
• About 10% of all cancer deaths that are not from smoking are related to obesity.
• In women who have obesity there are more thyroid cancers, leukemias, multiple myeloma, and pancreatic cancers.
• In men who have obesity there are more thyroid cancers, malignant melanomas, multiple myelomas, gallbladder cancers, and leukemias.

Even fertility is decreased by obesity.

• In women, 6% of those who are obese have trouble conceiving.
• When a pregnancy occurs, the chance of a serious event requiring hospitalization is 4-7 times greater for a woman with obesity compared to a woman who is lean.
• Gestational diabetes, difficulty with blood pressure control (pre-eclampsia), difficulties while in labor and delivery, higher c-section rates, and more deaths of the mother and/or fetus, are all associated with obesity.
• Children born to mothers who have obesity are more likely to be large. Large birth weight increases the risk of infants developing diabetes in later life.
• Men are also affected by obesity. Obesity causes erectile dysfunction (impotence) and lower fertility. Many men have low testosterone (male hormone) because they have excess abdominal fat.

Gallbladder disease is more likely in obesity.

• Compared with women who are lean, women with a BMI of over 32 have three times the risk of gallstones.
• In women with a BMI over 45, this risk is seven times higher.
• Changes in the liver that resemble alcoholic liver disease (known as fatty liver) can be seen with obesity. In 50% of patients, these changes will lead to fibrosis of the liver. In 30% cirrhosis will develop, and 3% will go on to develop liver failure.

Being obese also can affect kidney function. The kidney cannot filter well in people with chronic obesity. So kidney function is decreased by having excess weight alone.

Finally, the effect of obesity on emotional well-being is important to understand. In most societies, people with obesity are viewed as less desirable marriage partners, less likely to be promoted in their jobs, and tend to earn less than their more ideal-weight peers. Obesity can cost more, for example, many airlines now charge for two seats for a person with obesity. It is not surprising that obesity increases the risk of major depression. In turn, depression can lead to binge eating disorder and night eating disorder. Depression causes a vicious cycle leading to more weight gain.

Putting it all together

Obesity is a disease because it causes problems with your physical, mental and metabolic health. We have discussed examples of the complications of obesity. If you are unable to lose weight on your own, get help from your doctor. Chances are that it is not just the weight. Chances are you do have complications of obesity. Everyone who has obesity deserves a thorough medical exam at least yearly.

Clearly, the risk for many medical complications is increased with obesity. Even Hippocrates wrote so many years ago: Corpulence is not only a disease itself, but the harbinger of others.

Dace L. Trence, MD, FACE, completed undergraduate degrees in Biochemistry and Microbiology through the College of Biological Sciences at the University of Minnesota and her MD degree from the University of Minnesota Medical School. She completed an internal medicine residency through Northwestern Hospital in Minneapolis and, subsequently, returned to the University of Minnesota for Endocrine Fellowship. Dr. Trence started practice with Group Health, Inc, in Minnesota, becoming Chief of Endocrinology, initiating several programs, including a Lipids Clinic, Diabetes Foot Care Clinic, and a Diabetes and Pregnancy Clinic. After moving to Seattle to practice at Group Health of Puget Sound, becoming Chief of Endocrinology, then Chief of Medical Subspecialties, she then joined the faculty at the University of Washington. Currently she is an Associate Professor in the Department of Medicine, Director of the Diabetes Care Center and Director of the Endocrine Fellowship Program at the University of Washington.