Weight Loss Success: Make New Habits or Break the Old?

Which works better for weight loss: creating new healthy habits or getting rid of bad ones? 

A small but clinically significant study was recently published in the International Journal of Obesity that addressed this question. The good news is that BOTH interventions produced sustained weight loss at one year, with the 21 adults who created new habits having a 6.2% weight loss (roughly 12.5 lbs) and the 22 adults who worked on breaking unhealthy habits having a 4.8% (10.1 lbs) weight loss. 


The intervention group that tried new habits followed the researcher's "Top Ten Tips" which included fairly predictable weight loss strategies such as walking 10,000 steps/day; reading labels, watching portion size and reducing fat content; packing snacks and sticking to a meal routine; choose water over other drinks; slow down and be mindful while eating; and of course, my standard preach of at LEAST 5 servings of fruits and veggies per day.

Interestingly, the bad habit breaking group was called "Do Something Different" (DSD). The concept was to "increase behavioral flexibility" by being assigned a different task to perform each day during the 9 week initial intervention. Tasks could include choosing a different route to work or wearing a new outfit, or even writing a short story.

I love the focus on all-around behavioral flexibility that includes new healthy habits. Consider challenging yourself (or better yet, share a challenge with a friend or family member to increase your accountability) to "Do Something Different" each day on your path to a healthier you. My challenge today? Substitute water for my recently "snuck back in" habit of having a soda with my lunch. 

Is it a New or Old Weight Loss Drug?

This month I am talking about obesity & weight loss. By our human (and American) nature, we would all like a quick fix to solve our weight issues. This summer, the FDA approved not one, but TWO new weight loss drugs.  My last blog addressed lorcaserin (Belviq), and today's focus is really something old in a new package.

Qsymia was FDA approved in July 2012, and it is a combination of two older drugs that have been used independently to help with weight loss: phentermine and topiramate. Phentermine is an appetite suppressant, and was half of the infamous fen-fen (a diet pill combo that was removed from the market once its use was associated with the development of pulmonary hypertension (a damaging condition in the lungs) and heart valve issues. Phentermine by itself is still approved for "short term" use- a few weeks- as an appetite suppressant, but there is limited efficacy and safety data available. Topiramate was originally classified as an anti-seizure medication, but indications now also include migraine prevention. Physicians and patients were generally pleased to see that a side effect of topiramate is weight loss (to the point where I have had patients without frequent migraines ask if I will prescribe this drug "just in case"!)

Qsymia combines these two drugs, and showed significant weight loss at one year- an average of 8.9%.
Both drug components are  at much lower doses than the individual drugs are typically prescribed, which hopefully will limit side effects. Indications for this new drug are for patients who have a BMI>30 (defined as obese) OR if they are overweight (BMI>27) AND have high blood pressure, diabetes, or high cholesterol.

If you meet those qualifications and are interested in trying this new drug, don't rush to your doctor quite yet! Qsymia is not yet in pharmacies, though it is anticipated to be in "certified pharmacies" next month (September 2012).

BOTTOM LINE: The newly approved weight loss medication, Qsymia, combines two older medications and may prove to be significantly effective in helping treat obesity, but it is not available quite yet. 

You're "Obese"- Now What?

Yesterday's WAKE UP blog entry referred to the USPSTF recommendation that all patients who have a BMI >30 should be referred to an "intensive, multicomponent behavioral intervention" in order to lose weight and therefore decrease their health risk. These recommendations are evidence-based, focusing on patient outcomes (disease states, not purely lab numbers).

What is "intensive"? 

• 12-26 sessions per year (often weekly to begin, then monthly.)

What is "multicomponent"?

• Individual or group sessions with physicians, dietitians, and other trained providers
• Include physical activity
• Address issues that keep people from changing behaviors
• Encourage self-monitering of nutrition and exercise

What results can be expected? 

• Weight loss typically ranges from 8.8-15.4 pounds in the first year
• Glucose tolerance is greatly improved- in fact,  that there is a 50% decrease in new diabetes diagnoses in only 2-3 years 
• Cardiovascular risk factors are improved (lower cholesterol & lower blood pressures)

If your BMI is >30, you are more likely to develop heart disease, strokes, high blood pressure, diabetes, certain cancers (esophagus, breast, uterine, colon, kidney, thyroid,  and gall bladder). It doesn't matter if you LOOK "okay"- this is NOT a cosmetic issue! While 15 pounds may not be all you need to lose, often that is enough weight loss to make a very significant positive impact on your health

BOTTOM LINE: Talk with your doctor about your BMI at this year's annual physical, and prioritize a healthier lifestyle starting today.

WAKE UP America- Courtesy of Colorado!

This summer I had the pleasure of spending some time in the gorgeous mountains of Colorado, a state which has long been one of the "healthiest" state in the nation- especially as measured by weight. Colorado has "only" 20.7% of the population with a BMI (body mass index) that indicates obesity, compared with 35.7% of overall American adults who are obese. That's ONE in THREE American adults who are obese! But I digress...my point was going to be that as our family watched some of the Olympics on tv, we saw a Colorado health-awareness commercial that I thought was extremely well done. The commercial shows people waking up in bed, challenging the Colorado population to actually "WAKE UP" and look in the mirror and see their true reflection- not the image in their head. The point is that obesity is "not as extreme as you think", and certainly my clinical experience echoes that thought.

Most adults are so comfortable with the notion that they "will never look like/ weigh what they did in high school" to the point that as they carry around an extra 20-30 pounds, it doesn't occur to them that they are jeopardizing their health in any way. And their physicians (who are not immune to the same beliefs for both themselves AND their patients) are along for that joy ride.

In June of this year, the  United States Preventative Service Task Force issued an update to physicians regarding screening for obesity. We are called to screen EVERY adult (which means get a weight & height & determine a BMI) and then for every patient who is obese- meaning a BMI >30- we should direct them to an "intensive, multi-component behavioral intervention". What is that and why? More on this tomorrow...

BOTTOM LINE: "WAKE UP", step on a scale & check your BMI today- don't assume weight is not an issue if you don't "look" or "feel" obese. 

PS. It's the FIRST of the month- change those air filters!

What is BMI?

Yesterday, I mentioned that discussing your BMI with your doctor might be a less emotionally charged way to discuss your weight. Terms like "overweight" and "obese" tend to make us all shut down and stop listening, but it is really important to understand whether or not your weight is becoming a medical issue. The BMI is your "Body Mass Index", and it is a reflection of your relative body fat. Note that I said "reflection"- the BMI is NOT a precise measure of your body fat percentage.

BMI is simply calculated by using a person's weight and height. Specifically, BMI equals your weight in pounds multiplied by 4.88, divided by the square of your height in feet. There are charts to look at and on line calculators as well. Click on this link to the U.S Dept. of Health & Human Services' BMI calculator to see what YOUR BMI is today.

Now that you've got your number, what does it mean? Well, if you are less than 20, you are underweight. If you are between 20-25, you are considered healthy, or "normal" weight. Please pay attention if you are in the 25-29 segment, because you are overweight! If you are >30, you fall into the medical definition of obesity.

Why did I bold face that 25-29 segment? Because in my clinical experience, no one with a BMI of 30 or more is surprised that they weigh too much. However, I would estimate that over HALF of my patients who fall in the "overweight" category are shocked that they have a medical issue with their weight. After college, people often put on a couple pounds per year, very slowly creeping that scale. During that time, they may only go up a size or two in clothing, especially if they are buying more expensive clothes (which tend to run larger and larger.) Before they realize it, they weigh 20 or 30 pounds more than is healthy, yet they don't "feel fat". I don't care very much about cosmetic issues with weight, but I care deeply about increased risk of diabetes, heart disease, low back and joint pain, all of which come into play when your weight goes up.

BMI's are not flawless. If you are an "ARNOLD" with tons of huge muscles, your BMI will be falsely elevated. If you are elderly and frail, chances are good that your BMI underestimates your body fat. In general, however, the BMI is a great tool to assess your weight.

BOTTOM LINE: Take a moment and calculate your BMI, and take an honest look at your weight: 1/3 of Americans are overweight, 1/3 are obese, and only 1/3 are normal or underweight, so the odds are stacked against you.

Why Don't Doctors Talk about Weight?

I have often heard people complain that their doctor did not tell their spouse to lose weight. (While I could do a side blog on why it is that people have this complaint more about their spouse than themselves, I will pass on that aspect today.) The CDC reported that in a recent Disease Control and Prevention survey, only 42% of obese patients were advised by their health care providers to lose weight. Interestingly, those who WERE counseled to lose weight were more likely to be actively trying to do so.

Why don't doctors tackle this more often? Obviously, there are many reasons, but let me list the top ones that immediately come to mind.

1. TIME- Doctors are all frustrated with less and less time with our patients. Weight loss conversations are rarely brief (and often loaded with emotional baggage) so doctors may avoid the topic purely from lack of time.

2. FEELINGS- Doctors are human (mostly) too, and we don't want to insult or hurt people's feelings. No one seems to be offended by high cholesterol or blood pressure, but universally people are defensive and/or hurt when say they are overweight or obese. Certainly, our society has made fat a four letter word.

3. MIRRORS- If your doctor is overweight, he or she may consciously avoid discussions of weight (why can't you lose your weight, doc?) or subconsciously avoid the topic because of their own frustration with the issue.

4. EXPERTISE- Not all physicians receive equal training in nutrition, so we have different comfort levels in direct counseling. Having said that, know that we can refer to our wonderful colleagues- our registered dietitians- who specialize in nutrition.

So, on your next office visit, why not ask your doctor about your weight? I think the least stigmatized way is to ask about your BMI- your body mass index. What's a BMI? More on that tomorrow...

BOTTOM LINE: Obesity should not fall into the "don't ask, don't tell" category- ask your doctor if you are at a healthy weight!

How are the Poor Obese?

When did it become the norm that poor people are obese? Right now, 1 in 3 Americans are obese, and nearly 2 in 3 are overweight or obese. Throughout history, the poor have been HUNGRY...and thin. Meat has become cheaper than grains and vegetables, while we super-size and sugar everything. Check out the CDC's latest info on obesity in America for some shocking statistics...

Remember when going to the ice cream store meant picking out a single scoop of your favorite one of 31 flavors? Now the ice cream is simply the base, and we put multiple toppings of fudge and CANDY on top of our multiple scoops. In simply the past decade, fast food sales climbed from $107,147 BILLION to $164,836 BILLION dollars per year. Hmm...what if we spent some of those BILLIONS on health promotion, instead?

Obesity has numerous health consequences: Type 2 Diabetes, heart disease, high blood pressure, stroke, cancers (such as colon, breast and uterine), liver disease, sleep apnea and joint problems (especially knee and hip.) Our estimated obesity-related medical costs as a nation are $147 Billion annually. The obese INDIVIDUAL spends at least $1400 more on their medical care than a normal weight person.

BOTTOM LINE: Stop looking for the perfect diet, diet pill, or most amazing gym, and start making common sense small changes, like focusing on eating MORE vegetables and fruits and getting MORE active!

New USDA Guidelines

On January 31, 2011, the United States Department of Agriculture (USDA) released their updated guidelines for the American diet. A panel of 13 nutritional experts, chaired by Linda Van Horn (who has a doctorate in addition to being a licensed and registered dietician) reviewed the available evidenced-based data regarding the impact of diet on wellness and disease prevention. Their findings come as no surprise, with an emphasis on MAINTAINING a HEALTHY WEIGHT (through calorie balance- energy OUT equalling or exceeding energy IN) and focusing on consuming NUTRIENT DENSE foods and drinks.
What does this mean? In short:
MORE: vegetables, fruits, nuts, seeds, seafood, low- or no-fat milk products, eggs, poultry and whole grains.
LESS: Everything else. Seriously! Less solid fats, complex/refined sugars (crackers, cookies, breads, sweets), fatty meats, and drinks with empty calories like sodas, many fruit drinks and alcohol.

So none of this is shocking. Perhaps the one controversy is the level of salt recommended. The USDA okays up to 2300 mg of sodium for the general population, but the American Heart Association (worried appropriately about high blood pressure) suggests that really everyone should max out their salt around 1500mg. The reality is, however, that if people change their diet from highly processed foods to more plant-based and whole foods, their sodium content will fall as well.

WIth more than 1/3 of American children and 2/3 of our adults falling in the overweight or obese category, the USDA is rightly shifting the emphasis of their guidelines towards calorie balanced diets and LIFETIME weight maintenance, through increasing activity as well as increasing vegetable and fruit consumption. Tomorrow I'm going to return to focusing on the MORE philosophy that has successfully helped many of my patients reach their healthy weights.

BOTTOM LINE: (Straight out of the USDA's Press Release)"The bottom line is that most Americans need to trim our waistlines to reduce the risk of developing diet-related chronic disease. Improving our eating habits is not only good for every individual and family, but also for our country." Cheers.

MORE- A Novel "Diet"

On this last day of the 2010 AAFP Scientific Assembly, I will be speaking about nutrition. As family physicians, we are all motivated to help our patients achieve the best health they can, and often the major issues stem from being overweight. We know excess weight leads to high blood pressure, elevated sugars and diabetes, and high cholesterol levels, which can lead to heart attacks and strokes. So why don't more family doctors talk to their patients about their weight?

Of course, there are many reasons, but here are a few:
1. The doctor doesn't want to insult or upset the patient by telling them they are overweight, especially if the doctor herself is overweight.
2. Weight loss counseling can be very time consuming, and we are already time pressured without opening this can of worms.
3. Many doctors lack knowledge or training regarding current nutrition, and are unsure of which "diet" to recommend.
4. Often patients want weight loss drugs, and most doctors are unsure of the risks and aware of the high percentage of relapse once the medication is stopped.

My goal today will be to teach primary care physicians some simple tools that they can use to help motivate their patients to lose weight. They will learn about BMI, 24 hour dietary recalls and exercise prescriptions, and learn about my MORE philosophy! We all know that MORE fruits and veggies will push us towards better health, but having a concrete plan for More fruits/veggies, Optimizing Snacks, Ramping up Fiber and Exercising daily will be a terrific start! In fact, our surgeon general, Dr. Regina Benjamin, emphasized that we need to stop focusing on what we CANNOT have/eat, and start focusing on what we can and should be eating, which is exactly the MORE message I have been sending the past few years

BOTTOM LINE: Focus on MORE fruits and veggies, MORE exercise, MORE fiber and stop the culture of restrictive dieting!