No matter how much we wish it weren’t true, the scale doesn’t lie: Americans are overweight and getting heavier each year. According to the Centers for Disease Control and Prevention, 39.8 percent — more than…
No matter how much we wish it weren’t true, the scale doesn’t lie: Americans are overweight and getting heavier each year. According to the Centers for Disease Control and Prevention, 39.8 percent — more than 93 million — adults in the U.S. are obese.
The obesity rate in America has spiked over the past decade — no doubt the result of a combination of factors including sedentary lifestyles and constant access to high-calorie foods. This is a problem because we know that obesity is associated with serious health risks, including diabetes, cardiovascular disease and cancer. In 2013, the American Medical Association officially recognized obesity as a chronic disease and not just a risk factor for other chronic diseases.
Obesity is currently calculated using the Body Mass Index scale, an imperfect shorthand to describe a person’s metabolic health that divides weight by height. The National Heart, Lung, and Blood Institute offers an online BMI calculator that will do the math for you. Adults with a BMI between 18.5 and 24.9 are considered normal weight. Overweight is defined as a BMI between 25 and 29.9. If your BMI is 30 or higher, you’re considered obese. Although the BMI cannot account for variations in bone structure and muscular development, many doctors still rely on it as a quick way to calculate a person’s need for intervention.
If you’re struggling with obesity, the good news is there are treatments available to help you tackle the problem. Dr. Firas Akhrass, an endocrinologist with the Diabetes & Glandular Disease Clinic in San Antonio, Texas, says you have some options and an endocrinologist may be able to help. Endocrinologists are experts in metabolism and how the body converts food to energy and how glands and hormones work. Some endocrinologists specialize in the treatment of obesity and other metabolic disorders.
Changing the way you eat and how much you move is the best place to start when trying to tackle a weight problem, Akhrass says. “We always start with lifestyle changes. By far, it’s the most important thing. I often tell my patients, ‘The best medicine for you is called Nike.’ I don’t mean that as a product, I mean that as being active. The best medicine for you is being active,” he says.
Moving more and eating more nutritious foods that are lighter in calories but high in vitamins and minerals can make a big difference in body weight and overall health. “A negative balance of 100 calories per day on average will translate to a 10-pound weight loss per year,” Akhrass says. That 100 calories can come from eating 100 fewer calories or adding “20 minutes of activity per day. Just 20 minutes of activity can burn 100 calories,” which when applied consistently can add up to a 10-pound weight loss in a year. Akhrass says even a 5 percent reduction in body weight “can have a significant impact on the patient.”
But these interventions take time. “It took you a while to get there so it’s going to take a while to improve,” he says, and being patient and consistent in your approach is important. Most people who are struggling with obesity will also see a dietitian or nutritionist to help them develop a sustainable way of eating and to be sure that reducing calories doesn’t result in malnutrition.
Adding exercise and improving your diet are perhaps the safest ways to reduce body weight, but Akhrass says “unfortunately lifestyle change is not going to work for everyone.” In some cases, patients need more support and pharmacological intervention may help. Again, Akhrass says patients have some options, with the most commonly prescribed medication being phentermine.
Phentermine acts as a metabolic stimulant and appetite suppressant. It was first approved by the FDA in 1959, but got a bad rap in the 1990s after a spate of overdoses led the FDA to pull approval of the controversial weight-loss drug Fen-Phen, which was a combination of phentermine and fenfluramine, an appetite suppressant that could cause heart valve damage. Although Fen-Phen was discontinued, phentermine wasn’t — it was considered dangerous only in combination with fenfluramine.
Today, some endocrinologists and weight loss specialists prescribe phentermine (sold under several brand names including Lomaira, Suprenza and Adipex-P) to help patients lose weight. Chemically, phentermine is related to amphetamine, so it’s a controlled substance, but in certain doses and for the right patients, it can make a big difference, Akhrass says.
But still for some patients, medications aren’t the answer either, and for these individuals, a more permanent intervention may be needed. Bariatric surgery is an option available to certain obese people who meet specific criteria, and a surgeon who specializes in these procedures may be able to help you.
Dr. Anthony Petrick, a bariatric surgeon with Geisinger Medical Center in Danville, Pennsylvania says that “metabolic surgery is a more accurate description” for surgical interventions used to treat obesity, because they aren’t intended solely to reduce a person’s body weight, but to also address comorbidities of obesity such as diabetes and hypertension.
Not every obese person will be eligible for surgery, and doctors typically use BMI to determine whether someone should be considering this approach. “They need to have a BMI of greater than 35 and one poorly controlled comorbidity related to obesity,” he says. Alternatively, “if they don’t have a comorbidity, then a BMI of 40 or greater” and otherwise good health can qualify a person for bariatric or metabolic surgery.
In addition to helping patients drop pounds quickly, metabolic surgery has been shown to alleviate comorbidities, Petrick says. “This surgery was able to cause many of the common medical problems associated with obesity into a partial or complete remission. We’re not curing them, but diseases like diabetes can go into complete remission where the patient no longer needs medication or can significantly lower their doses.”
Reducing excess body weight also alleviates strain on joints and ligaments, making it easier for people to move more and further advance weight loss gains. Bariatric surgery “can’t change degenerative joint problems,” Petrick says, but for problems associated with strain from too much weight, dropping a few percentage points worth of body weight can make a big difference in how much pain or discomfort a patient must deal with daily, leading to big “quality of life benefits,” Petrick says.
Most bariatric procedures alter the size or shape of the stomach or other digestive organs to limit the amount of food a person can ingest or reduce the number of calories they can absorb from food that’s been ingested. There are currently four types of bariatric surgery used commonly in the U.S.:
— Gastric bypass, during which the surgeon makes a small pouch at the top of the stomach. The pouch is the only part of the stomach that receives food, thereby limiting how much you can eat in one sitting. A portion of the intestines are also reconfigured, which means fewer calories can be absorbed from digested food.
— Gastric banding, which uses a band to create a small pouch at the top of the stomach. This approach restricts the amount of food your stomach can hold, but because the intestines are not rerouted, it doesn’t affect the absorption of calories.
— Sleeve gastrectomy, in which part of the stomach is removed from the body and the remaining portion is reshaped into a tube. The smaller stomach holds less food and also produces less ghrelin, an appetite stimulating hormone.
— Duodenal switch with biliopancreatic diversion, in which the surgeon removes part of the stomach and bypasses the middle section of the intestine, so that food does not pass through most of the small intestine and the number of calories and nutrients are limited.
These are complicated procedures and major surgeries that have pros and cons associated with them. They can lead to rapid weight loss but should not be entered into lightly. Although the average recovery time in hospital is usually two days (many of these procedures can be done with minimally invasive approaches), patients need to be fully engaged with their recovery and change habits to make sure their surgery is a success. “The biggest adjustment is getting back to eating,” Petrick says, and it often takes a month or so before patients are back to eating solid foods. The amount of food they can eat is typically much reduced, so adjusting to a new relationship with food can be emotionally difficult for some patients. Petrick says it’s also critical that patients take vitamin and mineral supplements as directed by their physician, because these procedures can reduce the number of necessary micronutrients they can derive from food.
“Patients have to understand that it’s not just an operation and you’re done,” he says, but rather that maintaining weight loss after bariatric surgery will be a lifelong endeavor. He also says it’s critical to increase exercise, and advises patients to add “30 minutes of physical activity five times a week for an excellent chance of maintaining” the gains associated with metabolic surgery. It’s also possible for weight loss surgery to fail, and some patients regain all the weight after a period of years, so it’s important to keep tabs on your progress and visit your doctor as directed.
Still, it’s a good option that Petrick says he wishes more people knew they were eligible for. “We probably only treat about 1 percent of eligible patients,” but there’s “lots of good data to show” that metabolic surgery can improve quality of life, longevity and the incidence of obesity-related comorbidities.
Whether surgery is part of your journey or not, there is another type of doctor who may be able to help with obesity. Dr. Val Jones, a physiatrist and medical director of admissions at St. Luke’s Rehabilitation Institute in Spokane, Washington, says physiatrists may be able to help reduce the rates of obesity in America, especially for people who may be too heavy or have contraindications for surgical or drug interventions.
As a rehabilitation doctor, Jones says she would sometimes be asked to consult on how to get morbidly obese patients — in this instance meaning well over 400 pounds — more mobile and help them shed some pounds before undergoing surgery. “They called me because I’m the rehab doctor and I help people walk. [These patients] couldn’t walk because their size exceeded their capacity to be upright. These people are living in the hospital — they couldn’t go home” because they wouldn’t be able to care for themselves because of their limited mobility. And for patients whose weight exceeds what a nursing home could accommodate, getting stuck in the hospital sometimes happens.
Seeing patients with such stark needs sparked an idea for Jones. “If there’s anyone who can solve this problem, I think it would be a rehab doctor. We’re going to look at the patient from the perspective of ‘How can we get you to your goal?'” She says physiatrists are well accustomed to coordinating rehabilitative care, and in this sense, helping dangerously overweight people lose weight could be considered a form of rehabilitative medicine. “We can coordinate with the bariatric surgery team” to determine whether a patient is a good candidate for surgery or what needs to happen to help them become a better candidate. The rehabilitation doctor can prescribe certain exercises or physical therapy sessions that can help them reach their goal. For example, she says aquatic therapy can help patients weakened by inactivity begin to reclaim more mobility. “You get weak from just lying there, and they lie there because they’re too big to move. It’s a horrible cycle,” Jones says. But offloading some of that weight in the pool through the buoyancy that water offers can get an obese patient moving again, which will strengthen their muscles and help break the cycle.
“I felt that these people that everyone has given up on could be saved really and truly through the power of what rehab doctors do,” Jones says, and thus she developed a program in Spokane for patients needing this kind of intervention. “It’s been challenging because insurance has been a barrier. Insurance companies are not always willing to pay for services, especially if they’re a little outside the box,” she says, but each patient who finds success using this approach helps build the case that it’s a good investment for insurance companies to help other patients deal with obesity before it becomes an all-consuming and more expensive problem.