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Obesity

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Losing Weight: Evidence-Based Advice

In my sixteen years of family medicine, I think the most frustrating disease I treat is obesity. It’s frustrating because as a doctor I feel great compassion for these patients, trying so hard to lose weight, and yet I feel almost shameful that as a primary care physician I can’t offer much in terms of medicines to help. And now that I’m back in the USA after ten years in China, I’m very concerned that America’s struggle is even worse, with more than two thirds overweight or obese. So now, driven to seriously tackle this epidemic, I’ve scoured the literature for the most up-to-date, evidence-based advice on losing weight. Please feel free to print and share this.

Surgery

Let me jump right in to perhaps the most controversial point: I think that many, many more people should consider weight loss surgery. It literally is the most effective way not only to permanently cause weight loss, but it also literally can put diabetes in remission, lower your overall death rates, and lower your heart disease risks. A huge percentage of people can stop taking diabetes medicines after surgery. Don’t believe me? Feel free to read up on it, including a 2015 meta-analysis from JAMA, and the Cochrane library review from 2014. There are three major options:

  • Sleeve gastrectomy: This involves stapling off much of the stomach, leaving around 25% of the stomach. Average weight loss is 56%. This is now the most popular of the three.
  • Roux-en-Y gastric bypass: This is the most radical surgery, with the most complications, but also the most effective, with a weight loss up to 67%
  • Adjustable gastric banding: This involves putting a flexible silicone band around the top of the stomach, which essentially limits intake of food and makes you feel full with less food. The average weight loss for this is 44%, less than the other surgeries, and is now less commonly done.

Of course there are risks to these surgeries, and weight loss is disappointing for many afterwards. But in general, this is a far, far better option than the usual lifestyle struggles leading to maybe 10-20% loss at the most, with many gaining the weight back, and still having diabetes and other diseases. In fact, a recent 5-year study comparing weight loss surgery to lifestyle interventions showed a clear winner in the surgery group, with far more people losing much more weight, as well as putting diseases like diabetes in remission — totally stopping insulin injections and diabetes pills.

I seriously hope many people, especially in the high-risk categories, make an appointment with your local bariatric surgery teams and just talk with them, to discuss your options. If you’re in my Swedish system here in the Seattle area, you can sign up for their weight loss seminar and hear them out.

In terms of who should consider bariatric surgery, the current recommendations are:

  • Everyone — and I mean everyone — with a BMI (Body Mass Index) over 40, even without any other medical conditions, should consider bariatric surgery.
  • Anyone with a BMI 30-40 with diseases such as diabetes, high blood pressure, high cholesterol, sleep apnea, or severe arthritis, can also greatly benefit. Insurance companies usually would cover it if your BMI is over 35.

Do you know your BMI? A BMI over 25 is overweight, over 30 is obese. Here’s a calculator:

[bmi_calculator]

Prescription Medicines

My second main point, and perhaps even more controversial among physicians, is that prescription medicines can also help with weight loss. There now are four prescriptions and one OTC supplement which actually are FDA approved for weight loss, and these expanding choices are encouraging for us family physicians on the front lines. Most work by decreasing your hunger urges. All have side effects, of course, and weight loss varies from 7-12% on average, and people often regain the weight after stopping. But since even a 5% reduction in weight loss can greatly help reduce risks for diabetes, heart disease and arthritis, I think these are definitely worth considering, and I’m using more and more of these in my practice. I strongly suggest interested people (and doctors) read the 2016 meta-analysis in JAMA, comparing all five. The take-home message from this review is as follows:

  • The medicine phentermine/topiramate (Qsymia) is the most effective at weight loss, losing an average of 8.8 kg over a year, with side effects in the middle of the pack. This is currently my first choice for many. But one side effect is severe: birth defects, so all younger women have to take birth control and get monthly pregnancy tests while on this.
  • The combo medicine naltrexone/bupropion (Contrave) was less effective than Qsymia, with an average 5.0 kg weight loss, and more side effects — and also some debate about its safety with heart disease.
  • The OTC medicine orlistat (Xenical/Alli) is the least effective (2.6 kg weight loss), but has relatively fewer severe side effects (stomach issues), and also is the only one available without a prescription. You take it with each meal, and it decreases fat absorption.
  • The diabetes medicine Liraglutide (Saxenda) is second most effective for weight loss (5.3 kg), but has the most side effects. But it’s certainly a great option for those who have type 2 diabetes.
  • Lorcaserin (Belviq) has the least side effects but was second to last in effectiveness (3.2 kg weight loss).

Who’s a candidate for these prescription medicines? The FDA says that anyone with a BMI over 30, regardless of any illnesses, and also those with BMI 27-20 with risks (the usual ones mentioned above) could benefit from trying these medicines, at least for three months to see if you can get to 5% weight loss. If you do, great! Keep going! Hopefully your insurance will cover the cost (many do not).

Besides these medicines, I should also mention metformin. This common prescription medicine for type 2 diabetes also has the great side effect of weight loss, and while the overall loss is less than 5% in the studies, and thus is not FDA-approved for weight loss, it’s still a fantastic first choice for pre-diabetic people who are overweight. The famous Diabetes Prevention Program showed how even after ten years, the overweight group who took metformin 850 mg twice a day had an impressive 18% reduction in developing diabetes. (That’s impressive, but not nearly as impressive as the 34% risk reduction in the group that stuck to lifestyle changes: weight loss of 7%, 150 minutes a week of exercise, and diets focused on fewer calories and less fat.)

Diets

And now we finally arrive at the third controversial issue: diets. There’s so much overwhelming confusion out there, but I like to simplify it a lot by saying that it’s not so much what you eat, but how much you eat. In other words, calorie restriction is key. If you want to lose a pound a week, you need to eliminate 500 calories each day. This is basic biochemistry. (check out your specific needs using my weight loss calculator at the top right of this article). If you can do this daily calorie restriction, especially by decreasing simple carbs, great! Keep going!

But there’s an interesting newer option you may have heard about, called intermittent energy restriction (IER; the 5:2 diet). This has been trendy since 2013, with a BBC documentarybest selling book, and a British study showing how a twice a week regimen of cutting your calories (especially carbs) had similar or better results for insulin resistance and body fat than the group that followed daily calorie restriction. When we fast, even if only for 12-16 hours (nothing between dinner and lunch the next day), insulin resistance improves and fat starts to get reabsorbed. A recent review of all IER studies showed that the evidence for IER is promising — but still premature to fully endorse, with much more to learn about which pattern is most ideal, as well as long-term effects. Also, people who aren’t overweight and are trying this actually have a lot more side effects than benefits.

Otherwise, in terms of “diet”, it’s just overwhelming out there for people searching for the “right one”. An excellent review article this year does detail quite convincing evidence that a low-carb high-fat Atkins-style diet not only reduces the hunger urge, but also has clear benefits in insulin resistance, cardiac markers, and weight loss. The DASH diet really does help to lower blood pressure and weight, and the Mediterranean diet also seems to help with heart disease and some weight loss.

But again, the main issue for all of this diet talk is to focus not on food categories, but food quantity. It’s simple biochemistry: you have to have less energy intake to lose weight. Or you could increase energy output, which leads us to:

Exercise

For decades, the usual doctor spiel is to get 150 minutes a week of moderate exercise. But that hasn’t really translated into any meaningful changes nationally, has it? So here’s where another trendy (uh oh) regimen is gaining popularity, mostly because the growing research is impressive. It’s called High Intensity Interval Training (HIIT), and it basically means you go all out for 30-60 seconds on any activity, getting to maximum exertion, then take a few seconds break, then do another all-out effort, etc etc. You do this 15 minutes tops, twice a week only (typically). Check out an example in the image below from a New York Times article about a 7-minute workout, which I also blogged about in my New York Times column in China. This HIIT routine is great because it requires zero fancy equipment, and you can do it absolutely anywhere. Click here to access the online workout app.

The 7 Minute Workout. Source: New York Times

Supplements, Diets and Herbals:

This topic is actually less controversial for me, mostly because there’s an easy answer: most of those supplements have almost no hard evidence that they work well. I’m not confident enough about recommending any of the trendy ones, and that includes CLA, chromium, 5-HTP, and garcinia. I’m sure many of you are already taking some of these. You’re welcome to read the evidence, including some excellent supplement reviews by the Natural Medicines Database (paid);  The Encyclopedia of Natural & Alternative Treatments (free); The Cochrane Library; and The National Center for Complementary and Integrative Health (NCCIH).

Personally I’d much rather have my patients focus not on supplements but on calorie restriction. I’d also rather give them one of the prescription medicines above, which all have more evidence than any supplement.

If you must choose a supplement, at least you could try that OTC Orlistat with meals. And you could also consider soluble fiber such as blond psyllium. Used especially for constipation, it also helps lower cholesterol, control diabetes a tiny bit, and also help a bit with weight loss. You’d take it with food, and it absorbs fat from that meal. In fact, it’s now recommended that Orlistat users also take blond psyllium with each dose of Orlistat, as it prevents some of those unfortunate gastric effects.

Yogurt is also one of my favorite recommendations, not just for the way the probiotics help our microbiome and immune system, but also because the literature shows that yogurt helps to manage weight loss and waist circumference. I actually prefer higher fat than the low fat versions, and adding fresh fruit to non-sweetened yogurt is a great way to start your day. Add a pack of instant oatmeal, microwaved with soy milk, and you’ve got a healthy and filling breakfast.

Stand Up!

Did you know that sitting all day at work literally is harmful to your health? Recent data, including this 2015 meta-analysis of sedentary lifestyles, shows that the more you sit, the higher your risks for heart disease, obesity, diabetes and overall death rates. I just ordered a standing desk for my office! Here are more tips on how not to be a couch potato.

Use Smaller Plates

Americans definitely have suffered “portion distortion” over decades, as sizes for all types of food creep up and up. Remember how soda machines used to carry 12 ounce cans, and now all have 20 ounce bottles? How about a small popcorn at the movies? If we can’t control these external factors, at least at home we can control portion size, and one interesting step is to replace all of your usual large dinner plates with smaller plates, like the appetizer or salad plates. Recent studies, including the 2016 meta-analysis, do show that when people switch to smaller plates, they actually eat less. How easy is that?

Keeping It Off

It’s actually not super hard to lose weight — it’s keeping it off that’s the problem for most. Unfortunately, that’s a totally normal problem because our “hunger hormones” ghrelin and leptin reset to a new balance when we gain weight, and when we lose that weight, that hormone imbalance doesn’t reset well to the lower weight, and it thinks “I’m starving!” and compels you to eat more. Some tips to control this include healthy carbs, fiber, yogurt and protein (and not a high fat diet). Also, getting a good night’s sleep literally helps to reset those hunger hormones (that’s one reason why people with sleep apnea are at risk for gaining weight).

And for those who are in the higher obese categories with BMI over 35 or 40, gastric bypass surgery actually can permanently improve some of that hunger urge. How? Removing the top of the stomach in these surgeries removes the stomach tissues that secrete grehlin; less grehlin = less hunger signals = less eating = weight loss. That’s another important reason why I urge people to consider weight loss surgery.

My Bottom Line

After writing this article, I personally feel much more empowered as a doctor to help my patients lose weight. There are a lot more options than I had realized, and I’m definitely giving all of my overweight patients this article, and I look forward to working closely with my patients to help them lose weight in a healthy and permanent way. And hopefully I’ve helped you, as well!

Good luck!

Childhood Obesity: What Can We Do?

It’s no secret that children all over the world are putting on too much weight; in the US, an astonishing 1/3 of children are overweight or obese.  Being overweight as a child can lead to many diseases as an adult, including heart disease, diabetes, arthritis, high blood pressure, and some cancers. Also, overweight kids have lower self-esteem and higher risks for depression. So what can parents, or society really do to stop this epidemic? And how can family doctors and pediatricians help?

The first step parents should take is to find out where your child fits on a Body Mass Index (BMI) chart. Your doctor should be doing this at the well-child exams, but you can easily find childhood BMI calculators online (such as this one) and find out yourself. A child above 85% is considered overweight, and above 95% is obese. Many parents are surprised at finding their child is officially overweight or obese, which is why these objective BMI standards are important for tracking, as well as assessing progress.

There are quite a few weight loss approaches that most doctors can agree on; one major agreement is that diets almost never help, at any age. Any diet plan designed for quick weight loss is almost guaranteed to long-term failure, and many people frequently end up even heavier than before. The healthiest option is always slow and steady weight loss. One pound a week of weight loss for many children, from very conscious changes in diet and exercise routines, is appropriate.

Another major approach involves cutting back on TV time. The American Academy of Pediatrics just published a major policy statement stating that “the evidence linking excessive TV viewing and obesity is persuasive“. They specifically recommend a ban on junk- and fast-food advertising in all children’s TV programs, and they set specific limits of TV time for age groups. They also detail multiple studies showing how having a TV in the bedroom is another independent risk factor for obesity, both as a child and later as adults. They also recommended that “pediatricians need to ask 2 questions about media use at every visit: 1. How much screen time is being spent per day? and 2. Is there a TV set or Internet connection in the child’s bedroom?”

One approach I mentioned before was to have a good breakfast. Many studies have shown that eating a nutritious breakfast is crucial for a child’s physical growth and school performance, and that breakfast-skippers actually end up more overweight, both in childhood and later as adults.

Of course, the main treatments for obesity are the obvious: more exercise and eating proper foods in moderate amounts. It’s important that there be a family effort to help your overweight child lose weight. Parents also need to lead by example; it’s much harder for a child to lose weight if their parents are also overweight and don’t exercise. As for diet recommendations, the most obvious choices to eliminate are sodas and fruit drinks. Sodas truly have almost no redeeming value, especially for children. Any child drinking a daily soda is adding extra pounds of fat each year, and they are also increasing their risk for diabetes as well as teeth problems. Most fruit juices are also quite poor substitutes for natural fruits and should be used at a minimum. For exercise, most kids should be getting 60 minutes a day, but this can be broken up into multiple sessions. The key is finding something they love to do. And don’t forget that any exercise is better than nothing!

 

Another effort involves reviewing the foods at school. I recently heard the great news that milk producers in America reformulated their flavored milk to have 1/3 less sugars and calories. Many (but not all) nutritionists consider this a positive step, as schools that totally eliminated flavored milk encountered a large drop in milk drinking, which raises the risk of kids not getting enough nutrients such as calcium. What does your school do?

Parents who want to learn more about childhood obesity and how to fight it can find excellent resources at the website healthychildren.org, which is officially run by the American Academy of Pediatrics. And at familydoctor.org, the American Academy of Family Medicine also offers many tips on weight loss for all ages.

 

This post was originally published on my new blog at MyFamilyHealthGuide.com. Please follow my new blog! (and my Facebook page

In China, The Kids Are Not Alright

There’s a clever English language play on words, “assuming makes an ass out of you and me.” As an American expat straddling two cultures, I confess that it’s all too easy to make sweeping generalizations about differences, usually defaulting to my home country. But when it comes to health, I recently had felt that the average Chinese person is healthier than the average American. I was so convinced of this that I wrote an article on my blog asserting this. But after a chorus of criticism from my long term readers plus a rejection letter from my New York Times editor, I was forced to revisit my assumptions with better data. But I couldn’t find much supportive data at all. In fact, I uncovered much which makes me very worried about the future health of China’s children.

China exercise children obesity diabetes America USAMy main argument in favor of China’s health had centered around the sensory splendor of Beijing’s lively street life at night. On every street corner and in every park, generations of families, friends and neighbors dance en masse, sing along to classic tunes, and chat away while walking — often backwards. This happens every night in every season — in every city across China. It fits with a well known Chinese proverb 饭后百步走,活到九十九 (take a hundred steps after eating, live to be 99). There’s simply nothing like this social nightlife in America, and it’s a wonderful cultural tradition which I deeply wish we had in America. In top cities like enlightened and active San Francisco, there may be a few people walking their pets or jogging after dinner, but otherwise most American sidewalks are empty at night.

So from this wonderful nightly visual, I assumed that Chinese exercise a lot more than Americans. Here’s where the “assuming” part comes in: the statistical data doesn’t reflect this casual observation. Not even close, in fact. A 2008 survey, released by China’s State General Administration of Sport, found that only 6 percent of people aged 20 to 39 got the proper amount of exercise (90 minutes a week). This is far lower than the 26% in Americans aged 19-44 reported in the U.S. Health and Human Services report from 2012. This is also lower than their elders, which confirms the commonly noted observation that elderly Chinese get more exercise than the new generation — just the opposite of America. In China, 10% of people aged 50 to 69 carried out regular exercise, more than the 6% of their children and grandchildren. In the USA, 14% of persons age 65-74 got the recommended exercise, much less than the younger adult 26% rate.

What accounts for this striking difference in youth, also an ominous trend for China’s future health? One theory is the incredible amount of studying that Chinese students are accustomed to: a recent survey of 7,000 people in Shanghai and Hangzhou showed that children between grades 4 and 8 spend an average of 150 to 160 minutes doing homework every weekday and more than 200 minutes on weekends. In addition, children spend an average of more than 60 minutes every weekday sitting still and playing on computers, cell phones, tablets and watching TV. That’s an astonishing amount of homework, far more than the amounts I and my American friends and relatives ever had. In the UK, 9 to 11 year olds are expected to get 30 minutes a day of homework, going up to 90-150 minutes a day in high school. A 2010 China Daily article about this issue agreed that “China’s exam-obsessed education system is taking much of the blame for the deterioration in students’ conditions. “It’s the root reason,” said Sun Yunxiao, deputy director of the China Youth and Children Research Center. “The emphasis is on test scores, not physical well-being. Pupils are being assigned too much homework, leaving no time for exercise.”

This brings up an interesting and important topic of debate: what provides the better long term health for a child — a good education or proper exercise habits? After all, many studies show that higher education improves long term health, but studies also show that exercising is crucial for lowering lifetime risks of overall death, heart disease, cancers, diabetes and many other diseases. This imbalance is especially concerning since there is no strong evidence that more homework equals more lifetime success. In fact, many experts feel quite the opposite is true, especially during primary school ages. The American Academy of Pediatrics released a report in 2006 stressing that, “the most valuable and useful character traits that will prepare their children for success arise not from extracurricular or academic commitments but from a firm grounding in parental love, role modeling, and guidance.”

My wife and I love to spend our summer nights biking around our nearby hutongs and sometimes join in a dance. It’s one of the most charming traditions we have in China, and I can’t wait for our little Alex to join in the fun. I can only hope that other young people also join in, but the trend is not encouraging.

There’s a Good Reason You Can’t Lose Weight: Your Hormones Won’t Let You

obesity leptin ghrelinObesity is a major health crisis all over the world now, and it’s clear both to patients and to doctors that losing weight — and keeping it off — is incredibly difficult. Unfortunately there’s growing evidence why this is so: when you diet, your body’s hormones go into a permanent “fasting” state which never really reset after the ideal weight is achieved. The balance of hormones leptin and ghrelin basically make a dieter feel permanently hungry, and over 90% of dieters regain the weight they had shed, returning to their “new normal”. What this means for most people is twofold:

  • they shouldn’t beat themselves up for not losing weight because it’s biologically difficult;
  • it’s so much better never to be obese in the first place, as once you’ve gained the weight you’ll have major troubles losing it.

This provocative idea now has some serious research,  including one study covered here by one of Gina Kolata’s many excellent articles on obesity in the New York Times. She also had an outstanding, moving article called The Fat Trap last year which I highly recommend for anyone concerned about their weight. I discuss this concept on my March 8th radio discussion on EZFM; you can click on the links below to listen.

In this podcast we also discuss a Xinhua article discussing yet another study linking air pollution to cancers; this large study focused on diesel fumes causing lung cancers in miners in the US. Diesel pollution is a major issue here in China as well, so the health implications are all too relevant for us.

Click on the arrow below to listen to this podcast, or click here.
[podcast]http://66.147.244.109/~myfamio6/myhealthbeijing/wp-content/uploads/2012/03/030707_CUT.mp3[/podcast]

More Podcast Information

You can listen to all my previous podcasts at my podcast archive. You can always listen live to my radio interview each Wednesday around 7:35am Beijing time, on the Beijing Hour program on EZFM 91.5, which is broadcast from 7-8am every weekday by host Paul James. EZFM is the popular bilingual radio station on the China Radio International network, broadcasting here in Beijing and on multiple stations all over the world, as well as live online.

Obesity in Childhood: How To Stop the Epidemic?

obesity in childhoodIt’s no secret that children all over the world are putting on too much weight; in the US, an astonishing 1/3 of children are overweight or obese. Even in China, the obesity rates for children are dramatically rising. Being overweight as a child can lead to many diseases as an adult, including heart disease, diabetes, arthritis, high blood pressure, and some cancers. Also, overweight kids have lower self-esteem and higher risks for depression. So what can parents, or society really do to stop this epidemic? And how can family doctors and pediatricians help?

The first step parents should take is to find out where your child fits on a Body Mass Index (BMI) chart. Your doctor should be doing this at the well-child exams, but you can easily find childhood BMI calculators online (such as this one) and find out yourself. A child above 85% is considered overweight, and above 95% is obese. Many parents are surprised at finding their child is officially overweight or obese, which is why these objective BMI standards are important for tracking, as well as assessing progress.

There are quite a few weight loss approaches that most doctors can agree on; one major agreement is that diets almost never help, at any age. Any diet plan designed for quick weight loss is almost guaranteed to long-term failure, and many people frequently end up even heavier than before. The healthiest option is always slow and steady weight loss. One pound a week of weight loss for many children, from very conscious changes in diet and exercise routines, is appropriate.

Another major approach involves cutting back on TV time. The American Academy of Pediatrics just published a major policy statement stating that “the evidence linking excessive TV viewing and obesity is persuasive”. They specifically recommend a ban on junk- and fast-food advertising in all children’s TV programs, and they set specific limits of TV time for age groups. They also detail multiple studies showing how having a TV in the bedroom is another independent risk factor for obesity, both as a child and later as adults. They also recommended that “pediatricians need to ask 2 questions about media use at every visit: 1. How much screen time is being spent per day? and 2. Is there a TV set or Internet connection in the child’s bedroom?”

One approach I mentioned before was to have a good breakfast. Many studies have shown that eating a nutritious breakfast is crucial for a child’s physical growth and school performance, and that breakfast-skippers actually end up more overweight, both in childhood and later as adults.

Of course, the main treatments for obesity are the obvious: more exercise and eating proper foods in moderate amounts. It’s important that there be a family effort to help your overweight child lose weight. Parents also need to lead by example; it’s much harder for a child to lose weight if their parents are also overweight and don’t exercise. As for diet recommendations, the most obvious choices to eliminate are sodas and fruit drinks. Sodas truly have almost no redeeming value, especially for children. Any child drinking a daily soda is adding extra pounds of fat each year, and they are also increasing their risk for diabetes as well as teeth problems. Most fruit juices are also quite poor substitutes for natural fruits and should be used at a minimum. For exercise, most kids should be getting 60 minutes a day, but this can be broken up into multiple sessions. The key is finding something they love to do. And don’t forget that any exercise is better than nothing!

Another effort involves reviewing the foods at school. I recently heard the great news that milk producers in America this fall are all reformulating their flavoredmilk to have 1/3 less sugars and calories. Many (but not all) nutritionists consider this a positive step, as schools that totally eliminated flavored milk encountered a large drop in milk drinking, which raises the risk of kids not getting enough nutrients such as calcium. What does your school do?

Parents who want to learn more about childhood obesity and how to fight it can find excellent resources at the website healthychildren.org, which is officially run by the American Academy of Pediatrics. And at familydoctor.org, the American Academy of Family Medicine also offers many tips on weight loss for all ages.


(This article was originally printed in Beijing Kids magazine, where I am a contributing editor. You can click here to read the rest of my BeijingKids “The Doc Is In” columns.)