I used to be almost 500lbs. I had gastric sleeve surgery 2.5yrs ago, and lost over 300lbs. I'm maintaining around 180-185 now. I keep reading that obesity is a huge risk factor for Coronavirus. While I'm not longer obese, I was for over 25 years. Am at still in a high risk category?
Your answer will not change anything, I'm staying home regardless...Just curious.
Hi there – and congratulations!! That is an amazing thing that you have accomplished, and maintained, and I know how much work that takes! The relationship between obesity and COVID19 is very much on our minds. Obesity medicine experts have been writing about this in our medical journals and in the press a bit. There is great concern because other respiratory illnesses have worse outcomes in individuals with obesity. Because the countries that were previously affected by this epidemic do not have as high rates of obesity as we do in the US, there is concern that our population may have worse outcomes with a “dual” epidemic of obesity and this coronavirus. It has also been clear in other countries that weight-related medical conditions, like high blood pressure and diabetes, are associated with the worst outcomes. However, I have been keeping a very close eye and have not yet found analyses that really look at the correlation between body mass index (how we measure obesity clinically) and outcomes. So we have a lot more to learn. But if you have kept the weight off for this long are are at or close to a normal weight, I would not predict your history of obesity puts you in the highest risk category. Like you said, be as careful as we all need to be. And we are working to better understand how weight impacts the risks of COVID. Congrats again on your major achievement, you’ve had a tremendous impact on your health because of it.
Outside of Calories in and Calories Out, are there any other proven factors to account for in weight loss?
Hi! Thanks so much for this question. Calories in and calories out is important, unfortunately we can’t get away from that. But there are many other factors too. One thing we are learning increasingly more about is diet QUALITY. Many health factors improve by just improving diet quality, without weight loss (for ex blood pressure). And it seems that eating diets high in refined sugars may set us up to want more of that, and make changes in our metabolic response that do not promote weight loss, just the opposite. We are still learning more about this, but bottom line, diet quality is key. And physical activity – weight loss is increased by physical activity, but perhaps more importantly physical activity is a key factor in longer term maintenance of weight loss. And behavioral strategies are what help people “stick with” changes – which we all know is such a big challenge. All of these are the factors that we try to help people with when we work with them in a physician-supervised weight loss program. As you saw in my bio, I currently work at Form Health where we are providing this type of program, but all through telemedicine. I hope this gives a broad overview of your question. Bottom line – we cannot ignore calories. But we can do other things to complement the calorie-lowering efforts to ensure we are successful at weight loss! Best wishes! -FH
OMAD. Good or not? Fire away Doc.
I knew I would get a question on Intermittent Fasting! Perhaps the hottest topic of all in this field right now. For everyone else, OMAD = One Meal A Day. My overall approach as a physician, including in my focus on obesity medicine, is to recommend strategies that are evidence-based, meaning good scientific studies that support it works, and is safe. In animals, intermittent fasting had very impressive effects on weight and metabolic parameters like blood glucose regulation. In humans, studies of diets are hard, because it’s hard to get a large group of people to follow things exactly for a long time. Most studies are small in this area, and they are shorter term. They show that intermittent fasting does work as a strategy. It does not seem to cause adverse health effects. But it does not clearly and consistently win out over more “traditional” strategies, when it comes to weight loss over some time, if you compare head to head and follow out a bit longer. So when working with patients, I don’t by any means tell everyone this is the panacea and they should do it. I also do not discourage it if someone has found that it really works for them. I do try to help people fit it into their lives in a way that seems sustainable, because as I said in other posts, the key thing is to find a strategy that you can sustain. A strategy that will work for you, for the longer term. Some people love IF, and for others it is just not a good fit. There are interesting studies looking at the effects of this not just on weight, but on other health parameters. It may be an effective way to control hunger, and it may have some interesting effects on metabolism and sugar regulation, but studies again are small and not consistent. I think evidence is mounting (but still this is under study to determine what might be “best practice”) that if you do have a single meal and then a period of fasting, that you have the meal earlier in the day rather than later, as that aligns better with the circadian rhythms (daily variations) of metabolism, hunger hormone production, etc. This is a short answer to a topic that could long, and is complex. We are planning a webinar soon on the issue of meal timing, so if you want to friend Form Health on Facebook, you can tune into that – it will be myself and our wonderful Lead Dietitian at Form Health answering people’s questions on meal timing, live. Hope this answer is helpful! Thanks so much!
How often do you actually find that a medication/condition is significantly hindering weight loss?
Thanks for this thoughtful question. There are a few medical conditions that cause weight gain. They are generally rare, but how common is depends on the condition. Overall, finding one of these diseases in patients who present for weight loss is rare. However, it is not uncommon that people with obesity present to an obesity medicine specialist and are found to have weight-related medical conditions that were undiagnosed. For example, we find a lot of high blood pressure, fatty liver, and pre-diabetes, even in people who were under routine medical care. There is a long list of such conditions and how often each one might be found depends on the condition and the study, so it’s hard to give you specific numbers, but in my own practice this happens quite often. And the list of medications that cause weight gain is very long, so this is also not rare. It’s also important to know that the weight response to meds can be very individual, so a med that has not caused weight gain in one person may be causing it in another. So bottom line – the rare but serious medical conditions that cause weight gain are rare, but it happens a lot that people take medications that contribute to weight gain/inability to lose, and that we find undiagnosed health effects related to weight. The good news is that weight loss can make a big difference for the treatment of those conditions! Best wishes to you, FH
Hello Doctor, thank you for your advice and recommendations!
I've reached a plateau in my weight loss (62kg/1m70, late twenties (136 pounds/5.7) and I'm having a hard time with it. I reduced calories and increased cardio/weight lifting but the numbers won't budge. What are good/alternative strategies?
Hi there, thank you for your question. Based on your height and your weight as you provided in the question, you are at a healthy BMI, of 21.5. You don’t say where your weight loss journey started/how much you have lost, or if you had a specific goal. But right now you are at a healthy BMI, and your body is regulating hunger and energy burning to keep you there. If you are here after losing significant amount of weight, then the key thing now may be for you to focus on keeping it off – that can be just as hard! You should continue what you have been doing to lose - if not, you are likely to see your weight start to go back up again. I believe I have another posted question about maintaining weight loss, so please see my reply (in a few minutes) to that post, if it applies to you. Best wishes!
How much do the services you described cost the average patient? And how accessible are the services both locally and internationally?
Hi! Thanks for this! I believe you are referring to the cost of care at Form Health? Glad to hear you may be interested. I will refer you to the web for the pricing, because there are tiers and options, and because in solidarity to the community and the hardship that COVID19 has presented for us all, we are offering services at lower price. https://get.formhealth.co Available right now only in MA, soon in other states, but not internationally. Thanks and best wishes! FH
Do women with PCOS really have a lower BMR? Does this significantly impact weight loss efforts or is it marginal?
Hi there, Thanks for this question. Polycystic Ovarian Syndrome is a very interesting medical condition that we do not fully understand. There is a clear connection with weight, as women with PCO can resume menstrual regularity with weight loss, as one example. But there are a lot of studies that show that a comprehensive program, that includes nutrition, physical activity, and behavioral strategies (like the one that we provide through telemedicine at Form Health) can work. There are also studies of some of the weight loss medications in women with PCOS, that have shown effectiveness. I have worked with a lot of women with PCO, since I am an endocrinologist, and one of my favorite things as a doctor is to work with women who are trying to lose weight to increase their chances of becoming pregnant, because it is so rewarding for all of us when it works! Bottom line - women with PCO can lose weight through the same evidence-based strategies that work for others, and weight loss has very positive health benefits for PCO. So does exercise, by the way, even if weight does not change. Hope this helps!
Is there any way to minimize the weight fluctuations that happen as a result of loose skin?
I’ve lost 105 pounds (280 to 175 at 5’6”, F). The weight loss was achieved via calorie deficit over the past 18 months. I plan to continue losing weight until I am a healthy BMI.
I went on vacation in February and ate my maintenance calories/a little above. During that vacation I gained almost 12 pounds of water weight, and it was really uncomfortable (especially around my abdomen, where my loose skin is). It almost all went away/resolved itself within a week of eating to my normal, calorie controlled diet (1500 calories day + moderate exercise).
Will these fluctuations get better after a while of maintaining my loss? Is the only solution removal/surgery on the loose skin? Am i even correct to assume that the water weight I retained on this vacation was a direct consequence of my loose skin?
Thanks for your question! And first of all - congratulations!! That is amazing and I know how much effort that takes. Here are my thoughts. Weight fluctuations are normal. There are many factors that influence our weight, and for example retention of salt and water after high salt meals, or bowel movements, or time of day, these all contribute. I would suspect that the weight fluctuations you experienced on vacation were related to salt and water retention – this might be the case if you were eating out more or eating food cooked by someone else (who uses more salt) during vacation. It seems unlikely that 12 lbs would be fat loss and gain in such a short time, so I agree that this was water related. But I would wonder more about salt than loose skin. Loose skin is a real issue for some people who lose as much weight as you have. Sometimes this resolves over time, and if it does not, some people do seek surgical options, once their weight has been stable (this is key). I don’t know of any connection between water retention and loose skin – so I would have thought more about dietary aspects leading to water retention, and the skin issue as a separate. Hope that helps and keep up the great work maintaining all this weight you have lost. You have made a tremendous impact on your longterm health with this!
What is the best way to maintain the weight loss? Regaining weight is a huge problem.
Also, does lowering carb intake really help with cravings and binge eating?
Thanks for this post! And for highlighting the critical fact that losing weight is just a part of the effort – keeping it off for the longer term is hard work as well! Our body has all sorts of mechanisms that go into effect during and after weight loss, which are aimed at helping maintain weight/go back to where we started. We know when we lose weight hunger hormone levels get much higher, and metabolism (energy burned) gets slower. So all of the things that we do to lose weight successfully – we have to continue them! If you found a nutrition strategy that worked, you have to continue it. The same or more physical activity – this is a very key player in weight maintenance. Continue logging everything you eat, stay in close touch with your accountability and support system. For people who use weight loss meds, they often need to be continued (sometimes we also use meds to help people keep lost weight off if there is weight regain that cannot be curbed in other ways). Again, all of the components that we incorporate in our program, Form Health, and that will be in any high-quality and intensive weight loss program that bases its practices/recommendations on research. Best of luck- it is hard, but it is possible! And a final thought - for people who have the experience of losing but regaining repeatedly, and have obesity, they may benefit from trying a new strategy, like working with a doctor to see if weight loss meds might be an option, or considering a surgical approach. Thanks for the question!
How should a super morbidly obese person figure out their healthy weight range? Is it reasonable to expect them to be within the normal weight BMI range or is there another way they should be determining what a healthy weight looks like?
Another really great question. I had gotten another question about how to set an appropriate weight loss goals as well, and will address that one here too. This is one of the questions I get most frequently in my clinical practice, people want to know “how much should I weigh? What should be my goal/target weight?”. Here are the key things I would say. 1. Experts in our field have studied all the available science/evidence, and have come up with recommendations, guidelines. There is some variation depending on what guideline you read, but usually it is recommended that the goal be 5-10% of starting weight lost over 3-6 months. The reasons these are the goals come from medical studies. This is a) what can be achieved in studies where people have maximal support (this is referring to non-surgical weight loss), and b) this is what is medically significant. This is the good news. 5-10% weight loss is not easy to do, but it is doable, and can translate to reduction in risk of diabetes, less joint pain, improved quality of life, and a long list of other health benefits 2. You can set whatever goal you want! Some research has also shown that an individual setting “lofty” goals is ok, and does not mean they will do less well or feel disappointed with less – this has been an area of some scientific disagreement. You can also set a goal as above, and when you get there, set another goal, to go further. 3. We always have to have a long term maintenance goal too – someone is better off losing a more modest amount and keeping it off, than losing more but regaining it all back. 4. But bottom line to your question - as a doc with a focus on obesity medicine, I never tell people to reach “normal” BMI, and I advise against this when I teach other doctors, because our guidelines are clear this is not an obtainable goal many times – Hope this answers your question! You can calculate what a 5 and a 10% weight loss would be for you, and you can take heart that losing this much can bring big health wins! Best of luck!
How do you intertwine the self-confidence that is cultivated during an effective weight loss campaign and the current lack of social interaction? In other words, do you feel that a lack of social interaction may hinder ones ability/motivation to lose weight or is this a better situation to generate pure, self-focused motivation?
Hi! Thanks for this question. Physical distancing is affecting us all emotionally. I love your question because I have been really worried about exactly why you raise, which is why I am making myself available on forums like this, and trying to host some webinars too, to help support people who need it because they are trying to lose weight to improve their health and are finding it even more challenging that it usually is given social distancing. Our program in particular is all done through telemedicine, a decision we made way before this pandemic, because in general it is so difficult for people to have time for the many visits that a medical weight loss program usually requires – but support and connection and accountability are keys to success! Many many weight loss studies have confirmed this. We are lucky to be able to continue supporting people in the same way since our care is all virtual. I know that other programs are moving towards telemedical support as well. I would encourage you (or anyone) to think about who can support you in the process, and use the telephone or video conferencing to stay connected. Groups like this can be a community too. We all have to be sort of creative given what we are going through. But what you have highlighted is so important, so please continue to think about how you can get what you need within these confines. (And of course, we would be happy to help if you felt our program could be a right fit for you! https://get.formhealth.co) Best wishes!
I'm so curious if in your practice you're seeing particular links between adults experiencing super/morbid obesity and the ACE questions (Adverse Childhood Experiences), as the ACE study showed links between other health effects later on in life and early childhood traumatic experience(s). Or, do you screen for this? What's your take on doing trauma-informed practice within the obesity medicine field?
Thanks for such a thought-provoking and important question. Yes, many studies have shown that adverse life experiences, including in childhood, are risk factors for developing obesity. I believe that obesity is not one condition but really a broad range of pathophysiologic conditions – for some people the underlying biology and risks may be more genetic, for others more environmental, for others perhaps related to a childhood trauma, or a combination of many such factors. I certainly have a lot of clinical experience with victims of childhood or adolescence trauma who describe subsequently gaining a lot of weight. (By the way, childhood obesity is also lived as a traumatic experience with lasting psychological as well as health consequences). Having said this, we do not formally screen, we do not administer ACE questions, or other validated measures – what we do is ask people a lot about their life, their personal and medical history, and how that has related to weight. As I mentioned, tramautic experiences are often brought up in the course of treatment. It’s important clinical information because it may lead us to recommend additional treatment modalities, including with appropriately trained therapists, to complement the other weight management work that we do. But perhaps this should be something we need to be doing more! Would be great if interested people like you could do studies and help better inform our clinical care – we still have a lot to learn!
What kind of medications are available to prescribe? I'm familiar with alli/xenical/orlistat but interested in what the others are and how they work. Thank you!
Weight loss medications. Thanks for raising this. It is an important aspect of obesity medicine, and it is one of the ways in which working with a specialized doctor with advanced training in this can make a difference for people – for people, for example, in which other strategies have not worked. There are several FDA-approved weight loss medications. And let me be clear that I do not work with “supplements”, which are not FDA-regulated, and which make a lot of claims about success generally with no science to back it up. So. FDA-approved meds. Orlistat is the only one that works by blocking fat absorption in the gut. The others all work by suppressing appetites, by altering the signals that work in our brains to control hunger, fullness, cravings, interest in food, etc. Currently approved meds are phentermine, combo phentermine and topiramate (Qsymia), combo naltrexone and bupropion (Contrave) and liraglutide (Saxenda). These all work on different targets but they suppress appetite. For some of my patients, when combined with the right nutrition, physical activity, behavioral strategies and the right accountability and support, these meds can really be high impact. But there may be reasons someone should not take these meds, for example in certain medical conditions or in combo with other meds. So it’s important to work with a doctor who has the right training and always has your health and safety as a primary goal in working with you!
I am new FM doctor in the New England area, Just wrote the ABOM boards! I don't have any obesity mentors here so here we go:
1) Any thoughts on the most effective strategies on helping patients with weight loss in the primary care setting? 2) did your successful patients share a single trait that made them succeed at losing weight 3) what are your recommendations to patients have lost a considerable amount of weight on keeping it off long term given what we know about the body's metabolic changes
Hi! My time is up but since you are a colleague I wanted to reach out. You can carve out a great niche in primary care with ABOM certification, I know many people who get referrals from their own practice even, so have a sub-specialty within a group practice. Obesity is really a primary care issue! I don't think there is a single trait for success - and studies of predictors of success have really not been able to identify clear one - except for early success, which doesn't help much clinically! I did quickly post comments about weight maintenance to someone else's post, so hope you can read that one below. Best of luck! I encourage you to join The Obesity Society and/or OMA to find a community of like-minded docs, who do share tips and ideas and support... Happy you are doing this, we need more people specializing and knowledgeable in this!
Do you think that obesity is more of a physiological condition or a psychological condition? I feel like people always talk about changing behaviors, but if it's a physiological issue, that won't be effective. That's like telling a person with depression to just cheer up. It doesn't work because true depression is a physical problem, not mental. Do you think that maybe this is why the long-term success rate for weight loss is so incredibly low - because we treat it as a psychological issue rather than a physical one? I'm sure there are psychological elements to it, but it makes sense to me that in a lot of cases, it's more of a physical issue.
Hi, this is a very thoughtful question. As I just wrote in reply to someone else, I believe that obesity is not one condition but really a broad range of pathophysiologic conditions. But I want to be clear that science supports that a very complex system of hormones and metabolic cues regulate weight, it is not “psychological”. At the same time, for some people the risk may be more genetic, for others more environmental, for others more related more to psychological trauma, like someone else asked about – and generally in my experience it is a combination of many factors. We don’t have any way to test for these underlying conditions at this time, I hope research will help us be better at diagnosis some day, so we can be better at treatment! But obesity is a treatable condition. The combination of healthy nutrition, physical activity, and behavioral strategies can work. And when these do not work, or do not last, we can also use medications (will post more about this), we can recommend weight loss surgery – these are medical treatments that address more the “biological” components by changing our physiology. I also want to say that psychological aspects are very important – just as I wrote to someone else in a different context here, individuals with obesity face a lot of discrimination. So there is a lot of interaction between biology, emotional and psychological aspects, and environment. Thanks for the question – it highlights what a complex disease obesity is and how many aspects of a person’s life it touches!
Why are fat girls thinking that they are entitled to date a fit guy like myself?
I should ignore this post, but I can’t. Obesity is a chronic medical condition. Science has taught us so much about the biology of how our bodies regulate our weight. The genetics you inherit, the environment during fetal development, and so many other biological factors that affect our weight are out of our control. But in addition to the physical and emotional conditions that are associated with weight, individuals with obesity face a lot of discrimination. We ALL need to do our part to stand up against that, and to make it unacceptable to stigmatize a person or a group of people because of their weight. Please join us in building a kinder, more accepting culture. Great that you are fit and if you take exercise seriously you are doing good for yourself and your health. But it is not necessary to put anybody else down. This kind of language hurts us all.